PRACTICAL PSYCHOLOGY AND PSYCHIATRY C.B.BURR,M.D. ^Practical Psychology and Psychiatry FOR USE IN TRAINING-SCHOOLS FOR ATTENDANTS AND NURSES AND IN MEDICAL CLASSES, AND AS A READY REFERENCE FOR THE PRACTITIONER c. B. BURR, M.D. Medical Director of Oak Grove Hospital (Flint, Mich.) for Mental and Nervous Diseases; Member of the American Medico-Psy- chological Association, of the American Medical Associa- tion, of the American Neurological Association ; Fel- low of the American College of Physicians; Foreign Associate Member of Societe Medico-Psychologique of Paris, etc. FIFTH EDITION REVISED AND ENLARGED WITH ILLUSTRATIONS PHILADELPHIA F. A. DAVIS COMPANY, PUBLISHERS , 1921 ftibrary of fiofam Janfcon ial COPYRIGHT, 1898 COPYRIGHT, 1906 COPYRIGHT, 1914 COPYRIGHT. 1921 BY F. A. DAVIS COMPANY Copyright, Great Britain. All Rights Reserved PRESS OF F. A. DAVIS COMPANY PHILADELPHIA. U.S.A. PREFACE TO FIFTH EDITION IN this revision important additions have been made to the Chapters on Psychology and Forms of Insanity. As to classification, the recommendations of the National Committee for Mental Hygiene have been largely adopted. A new chapter on the Preven- tion of Insanity has been incorporated. Very sincere thanks are extended to Dr. M. W. Clift, of Flint, for the drawing of the Sympathetic Nervous System which appears in Part I. C. B. B. Flint, Mich. (Hi) CONTENTS PART ! PAGE Psychology 1 Life; the Brain; the Mind; Faculties of Mind. Thinking 13 Development of the Mind; the Senses; Sensa- tion; Perception; Memory; Ideation; Reason- ing; Judgment. The Localization of Function in the Brain 26 Feeling: Emotion 29 Volition 35 General Considerations 43 Sensation; Perception; Hallucinations; Illu- sions; Delusions; Witchcraft; Ideation; Mem- ory; Higher Reflexes; Volition; Concept Asso- ciation; Inattentiveness; Incoherence; Flight of Ideas; Verbigeration; Stereotypy; Pressure of Activity; Retardation; Opposition; Nega- tivism. PART II. Symbolism in Sanity and in Insanity, 58 Word Association and Obsession. PART III. Insanity 69 Definition. Causes 70 Direct Physical; Indirect Physical and Emo- tional; Vicious Habits; Constitutional and Evolutional. Forms of Insanity 74 Infection Psychoses 77 Fever Delirium 77 (v) VI CONTENTS. PAGE Infection Delirium 78 Postfebrile Conditions 79 Simple Neuritis 80 Treatment 81 Exhaustion Psychoses 81 Collapse Delirium 81 Acute Confusional Insanity 83 Chronic Nervous Exhaustion (Neurasthenia) . 85 Intoxication Psychoses 89 Lead Poisoning 89 Alcoholic Intoxication 89 Delirium Tremens .' 90 Dipsomania 93 Chronic Alcoholism 94 Alcoholic Delusional Insanity 94 Alcoholic Pseudoparesis 95 Alcoholic Paranoia 98 Alcoholic Epilepsy 99 Morphine and Opium Addiction 99 Cocaine Habituation 105 Insanities from Disturbance of Function of the Thyroid Gland 106 Myxedema 106 Cretinism 106 Hypo- and Hyper- thyroidism 107 Dementia Praecox 108 Hebephrenic Form 110 Katatonic Form 116 Paranoid Form 117 Paralytic Dementia 123 Elated Type; Depressed Type; Differential Diagnosis. Juvenile Paresis 137 Dementia with Paralysis '. 138 Insanity from Syphilis 139 Manic-depressive Insanity 139 Excited Phase 140 Depressed Phase 144 Alternating Type 150 CONTENTS. Vli PAGE The Presenile and Senile (Involutional) Insanities. 156 Epileptic Insanity 160 Psychoneuroses and Neuroses 161 Hysterical Type 161 Psychasthenic Type 165 Dual Personality 169 Fugues 171 Anxiety Neuroses 1 72 Idiocy and Imbecility 175 Paranoia 176 Pellagrous Insanity 190 PART IV. Management of Cases of Insanity from the Medical Standpoint 193 Medical Examiners; Diagnosis; Nursing Atten- tion; Medicinal Treatment; Bed Treatment; Enemata; Hydrotherapy; Mechanical Feeding; Othematoma; Travel; Hospital Care. PART V. Management of Cases of Insanity from the Nursing Standpoint 220 Qualifications of Nurse; Administration of Food; Administration of Medicine; Nursing; Correction of Pernicious Habits and Check- ing Morbid Impulses; Mechanical Restraint; Ethics. PART VI. The Prevention of Insanity 248 Discipline in Home; Self-helpfulness; Good Literature; Work; Children's Caprices; Mili- tary Training; Day Dreaming; Autistic Think- ing; Sex Education; Marriage. Index . , 259 ILLUSTRATIONS PAGE The Brain as Seen from the Right Side 5 Physiological Lobes of the Cerebrum 9 Neurone 11 Sensation 15 Perception 16 Concept 21 Zones and Centers of Cerebrum 26 Great Sympathetic Nervous System 31 Volition 38 Stereotypy 55 Handwriting in Paralytic Dementia 129 (viii) PART I. PSYCHOLOGY. PSYCHOLOGY : the Science of Mind. The word Psychology is derived from two Greek words: Psyche, Soul, Mind; and Logos, Discourse. The problems of the mind involve those of BIOLOGY : the Science of Life (Bios, Life; Logos, Discourse); and PHYSIOLOGY : the Science of properties and func- tions of Living Beings (Physis, Nature; and Logos}. LIFE is defined as "a relation or combination of mat- ter and force in which peculiar phenomena (ap- pearances) take place, which are: (1) motion from inherent power, (2) a capacity for appropriating nour- ishing material (assimilation), and (3) the capability of multiplication or reproduction for the preservation of species. In the higher forms differentiation 1 of structure and development occurs ; and, in the highest, sensibility (feeling), intellection (thought), and will (volition)." 2 That which distinguishes the living from the not living is the possession of the three qualities or attri- butes: Motion, Nutrition, and Reproduction as above mentioned. The locomotive moves from the force exerted by ex- pansion of water ; the automobile, from that occasioned 1 A production of diversity of parts by a process of evolu- tion or development. 2 The late Dr. A. B. Palmer. (1) 2 PSYCHOLOGY, by the sudden explosion of gases by means of an elec- tric spark. Inorganic substances change their positions from force exerted upon them (as the rolling of a stone from an earthquake upheaval). Heat and electricity are so-called modes of motion. The acid and the alkali, coming together in solution, make disturbance in the glass (motion from chemical action). All these are illustrations of motion, but not motion from inherent power. Stones enlarge by additions to their surfaces (accre- tion), but cannot appropriate (assimilate) substances with which to grow. Two or more stones may be produced from one by a process of breaking or disintegration. They have no ability, however, to reproduce their kind. Certain plants, on the contrary, demonstrably have motion from inherent power : as witness the sensitive plant, which closes when its leaves are touched; the morning-glory, which opens and closes its petals; the ivy, which climbs the conductor-pipe or the tree; the insect-eating plant, which closes about and absorbs the prey which alights upon it. Plants also have ability to appropriate nourishing material. This is absorbed from the soil, or from the atmosphere, or, as in the case of the insect-eating plant, as above shown. Plants reproduce their kind by contact of the male and fe- male elements. Conclusion (JUDGMENT) : Plants pos- sess life. The lowest form of animal life is that of the amoeba. This consists of a simple mass of albuminoid matter, possessing irritability (rudimentary sensation), con- tractility (enabling motion from inherent power), and the power of segmentation or division, through which PSYCHOLOGY. 3 it reproduces itself. From this low form of life up to man, showing the highest organization, differentiation of structure occurs. The lowest form of animal life in which a nervous apparatus (and this very rudimentary) appears is the jelly-fish. This animal possesses a muscular, digestive, and circulatory system sufficient for its needs. The oyster has imperfect nervous, muscular, circulatory, respiratory, and reproductive apparatus. The oyster has a bony system, its skeleton being upon the outside and constituting its shell. In the reptile and fish there is a higher development of the bony, muscular, diges- tive, circulatory, respiratory, nervous, and reproductive systems, with special adaptation of structure to the conditions in which the animal exists. Special senses (hearing, seeing, etc.), are not de- veloped in the lowest animal organisms. In the very lowest form, as the amceba, there is irritability; in higher, common sensation (impressions of pain). As the scale is ascended, the touch sense, and from this on, other senses, as vision, hearing, etc., develop. The nervous system in man is composed of : 1. A central portion originating and receptive. 2. A peripheral portion (the nerves) distributing from, and conducting to, the central. 3. The great sympathetic bordering the spinal column (see illustration, page 31), a chain of so- called ganglia and their nerve connections. Refer- ence to this is hereafter made under the head of Emotion. The divisions of the central portion are: 1. The encephalic within the skull. 4 PSYCHOLOGY. 2. The spinal (spinal cord) within the spinal bones. The part of the nervous system contained within the skull, composed of white and gray matter, and called the encephalon, or brain, has the following principal divisions : the cerebrum, the largest, con- sisting of two lobes or hemispheres connected by a bridge of white substance; the cerebellum, a smaller mass situated behind and below the cerebrum; the pons Varolii, a bridge which partially surrounds the legs or crura of the cerebrum and assists in binding the lobes of the cerebellum together, and the medulla oblongata, which in its lower portion is continuous with the spinal cord. Three membranes, the dura mater, arachnoid, and pia mater, envelop the brain and spinal cord, the pia lying close to them and the dura directly beneath the bones. In the higher animals, accompanying certain nervous manifestations, there appears what is called conscious- ness (mind). Fishes can be taught to come at the ring- ing of a bell ; perroquets and canaries to live in (stage) harmony with their hereditary enemy, the cat, to per- form acrobatic feats, propel carriages, fire miniature guns, engage in mimic battle and simulate death ; lions and leopards to perform tricks and subordinate savage instincts to the will of man; horses and pigs to indi- cate numbers; dogs to present an entire play, taking the parts of policeman, fireman, sentimental lover, busy housewife, and nurse for baby. Dogs often display a high type of reasoning and judgment. The word "in- stinct" employed as indicating the conduct-governing force in lower animals, formerly much in use, is now nearly discarded. Habit associations and inherited PSYCHOLOGY. 5 tendencies (instinctive) are numerous and obvious in these, but the psychologist no longer denies even to those low in the scale of intelligence a certain degree of ability to group concepts (reason) and to form judg- ments through which action is determined. In the highest form of life (mankind) the develop- ment of the brain and nervous system reaches its The brain as seen from the right side. (Mills, "Nervous Diseases," J. B. L. Co.) greatest perfection, and manifestations of mind are of the most complex character. The BRAIN is the organ of the mind. The cerebrum, with which in this connection we are chiefly concerned, is composed of white and gray matter. The white matter is fibrous, and makes up its bulk. The gray matter contains the cell elements, and 6 PSYCHOLOGY. is for the most part found upon its surface, although there are islands of this substance in the interior. The cortex, or covering of gray matter, dips down into grooves upon the surface of the brain, increasing its superficial area very considerably. The raised or prominent portions of the brain found between these grooves are called convolutions, and upon their depth and perfection of development mental strength largely depends. In lower forrm of life and in primitive peoples they are smaller and less definitely outlined than in the higher orders of mankind. The gray matter receives impressions from without conveyed by the sensory nerves and nerves of special sense and conducted through the white matter. The gray matter originates and sends out impulses through the white matter to other gray portions and through the white matter and nerves to the outside. The white matter conveys impulses from portions of the gray matter to others and conducts impressions to the gray matter received from without through the nerves. It also carries commands to the remotest portions of the body which result in movement. Nervous force originates in the gray matter. The nervous system is comparable roughly to an electric cir- cuit, with its battery of cells, in which force originates ; with its white matter of insulated wires, by which the current is conveyed ; and with relay stations or substa- tions, the gray islands at the base, in which messages from the central station are grouped and co-ordinated, and in which, under certain conditions, messages from without, carried by the nerves of sensation and special sense, are responded to without the intervention of the main office. PSYCHOLOGY. 7 Simplicity in the structure of the brain indicates low mental development, as shown in idiots and imbeciles. As complexity in structure increases, convolutions grow deeper, and gray matter becomes more abundant, men- tal operations are correspondingly higher. The size of the head, unless it exceeds or falls far below certain limits, is not indicative of the degree of mental develop- ment. 1 "No mental modification," says James, "ever occurs which is not accompanied or followed by a bodily change," and experiments upon the lower animals and observations in disease in man show that the brain is the organ of thought. Disturbance of its structure or function interferes with the play of emotion and the faculty of ideation. Serious and long-continued im- pairment of its nutrition displays itself in settled per- versions of thought and feeling. Injury resulting in cerebral concussion may cause temporary or permanent suspension of intellection, and defects in cerebral devel- opment are accompanied by partial or complete absence of the higher psychical processes. A child is born into the world the structure of whose brain is anatomically deficient, or the growth of which is impeded by me- chanical compression. The result is idiocy or imbecil- ity ; the development of the higher intelligence, of judg- ment and reasoning, is impossible. "The pursuance of future ends and the choice of means for their attain- ment," which, according to James, are "the mark and criterion of the presence of mentality," are absent. That the Brain is the organ of the mind, and that in 1 There are both microcephalic (small-brained) and mac- rocephalic (large-brained or at least large-headed) idiots. 8 PSYCHOLOGY. the Cerebrum (the large brain) reside the higher men- tal faculties, is shown : 1. By experiments on the lower animals. The pigeon deprived of the cerebrum remains apathetic and droop- ing. If thrown into the air, contact with this element produces, through what is known as reflex action, the muscular movements of flying, but these gradually be- come feebler until the bird sinks to the ground. If food is placed within its reach it is not voluntarily ap- propriated. If inserted far back in the mouth, food is swallowed through reflex action. The frog deprived of its cerebrum rights itself if an attempt is made to turn it over. If pricked or prodded, it jumps, but is quiet and motionless unless disturbed by contact with some- thing. It initiates nothing. The behavior of animals thus deprived of the cerebrum is akin to that of human beings suffering from profound dementia (acquired mental impairment). 2. By disease of the brain, which is so often asso- ciated with disturbance of the mental operations. 3. By the mental deficiencies which exist in connec- tion with lack of cerebral development, as in idiots and imbeciles. A definition of mind is impossible. It is known only through its operations. I am conscious of my mind from evidence within (subjective). I am conscious of mind in others because they act in obedience to out- ward, or apparent, circumstances as I do myself under similar conditions (objective evidence). Their so- called "reaction to their environment" is similar to my own. As to the relation between mind and brain, this much, and only this much, is definitely known, that upon the PSYCHOLOGY. 9 relative integrity of the latter, the natural operations of the former more or less closely depend. As to what consciousness is that subtle something through which we are made aware of ourselves, of our environment, of our relations to society, through which our feelings are stirred, by means of which we act and think intel- ligently we are on no better ground of knowledge than were the philosophers of long ago who knew Physiological lobes of the cerebrum, lateral aspect: S, Sylvian fissure ; C, central fissure or fissure of Rolando; Po, parieto-occipital fissure. (Mills, "Nerv- ous Diseases," J. B. L. Co.) not the use of the scalpel, the microscope, and the staining agent. The prefrontal lobes of the brain have been desig- nated the "higher psychical." This is perhaps objec- tionable, inasmuch as the brain in its entirety is the great psychical organ, and all portions of it in some way participate in the thinking processes; but it has been shown by investigations upon the brains of lower 10 PSYCHOLOGY. animals that, as a result of destruction of portions of these lobes, inhibitory (checking) control and capac- ity for close attention and intelligent observation are impaired. If they are destroyed completely there arise alterations in the personality and incapacity to form serially groups of images or re-presentations. The cortex, or gray covering of the brain, is largely composed of layers of nerve cells of different shape and size and of infinite number. Those of the so-called pyramidal cell layer are thought to be chiefly concerned with the psychical functions because of the peculiarities of their distribution and their numerical diminution and imperfection in the brains of those of low order of mental development, as idiots. The so-called psychical neurone is of tree-like form, the body, with the thicker portion of the process extending from it, representing the trunk, and the tuft-like expansion, the foliage. The neurone also has a body with nucleus 1 and nucleolus 2 and a system of fibers passing through it which unite at the basal end into the axis cylinder or axone, through which impulses generated within the cell-body are con- veyed outward. The prolongation from the cell, called the axone, is insulated by a sheath throughout its entire extent. This insulation is for the apparent purpose of prevent- ing dissemination of impulses along the fiber. Berkley says that the researches of Flechsig have shown that at the time of birth the human infant possesses only a narrow region bordering on a fissure, called the Rolan- dic, which contains fibers having these sheaths. In the first month two other small areas in the cortex show 1 A center of growth a kernel. 2 A body within the nucleus. PSYCHOLOGY. 11 Illustration of the neurone. A, axone with col- laterals; B, apical dendrite, showing gemmules; C, lateral dendrites; D, cell-body. (With grateful acknowledgment to J. F. Burkholder, M.D., Chicago.) 12 PSYCHOLOGY. beginning insulation, and from this time on, as intel- lectual activities increase, further and further insula- tion of fibers shows itself in other areas. He also says that in the earliest stages of brain growth when the nerve cells have reached nearly their adult proportions, Flechsig finds only four centers that show signs of a tendency toward individual insulation of the nerve fibers of the cortex. The principal fibrous prolongation after leaving the cell body throws off collateral branches. Through these collaterals association con- tacts in the brain are established, and upon the perfec- tion of their development and the multiplicity of their connections with other cells the faculties of discriminating judgment and of comparison of im- pressions with other impressions are supposed by some to depend. Association paths between the different areas of the same hemisphere and letween the two hemispheres by the bridge called corpus callosum are more numerous and intricate as mental development increases. Micro- scopical anatomy demonstrates that up to maturity there is a steady increase in means of association be- tween cells of the cortex. Each cell with its processes is separate and distinct from its fellows. It exists as an individual unit anatomically, and is independent of the myriads of others in the nervous system. Contact is not made directly between the prolongations of one cell and the tufts of others, but an interval exists, and upon the theory of failure of contact or delayed con- tact has been built up the retraction theory of psychical cell association. It has been assumed that in the rapid flow of ideation, this contact is continuous and exact, discontinuance or break resulting when the particular PSYCHOLOGY. 13 association in thought is no longer required or when the flow of ideation is arrested by fatigue or changed conditions. Thus the inability to recall a name or an incident may be due to the failure of contact between the different nerve-cell elements concerned in the asso- ciation which would in normal conditions arouse the memory. The faculties of mind are three : 1. THINKING (intellection, thought). 2. FEELING (sensibility, emotion). 3. ACTING (will, volition). Thinking. Development of the Mind. Knowledge is derived through the medium of the SPECIAL SENSES and mental development depends upon the reception of impressions from without and their comparison with those already stored in memory. These SPECIAL SENSES are six in number : 1. Hearing: mental impressions through the audi- tory apparatus. 2. Seeing: mental impressions through the visual ap- paratus. 3. Smelling: mental impressions through nerves sup- plied to the nasal mucous membrane. 4. Tasting: mental impressions through nerves sup- plied to the tongue. 5. Touch: mental impressions through sensory nerves supplied to external parts of the body, skin, and mucous membranes. library of Irttrt Jattimu U 14 PSYCHOLOGY. 6. Muscular: mental impressions as to force and re- sistance derived from contracting muscles. 1 There are necessary to the mental upbuilding : 1. SENSATION. 2. PERCEPTION. 3. MEMORY. 4. IDEATION. 5. REASONING. 6. JUDGMENT. A SENSATION is an impression made upon an organ of sense, which organ must be composed of three parts : 1. A nervous mechanism to receive the impression. 2. A sensory nerve, or nerve of special sense, % to con- vey the impression to the brain. 3. A nerve cell, or group of cells, to receive the im- pression. Take the eye for illustration. A ray of light from some object falls upon the retina. An impression is conveyed through the optic nerve to the center of sight in the brain and there received. This is a simple sen- sation. SIGHT, or SEEING, is a different thing, how- ever, and involves, just as hearing, smelling, touch, taste, and the muscular senses do, something else, which is called PERCEPTION. This is at the very foundation of thought and is the conscious recognition of the external causes of sensation. To illustrate: nothing is so helpless as the human 1 Compare the impression received from compressing a rubber ball with that from a similar attempt upon a piece of steel. The essential difference between the touch and the muscular sense is plainly apparent.' PSYCHOLOGY. 15 infant at birth. Unlike the chick, which as soon as it emerges from the shell helps itself to food placed in the incubator, the child is utterly dependent and with- out means for self-preservation or protection. It is an unorganized bundle of tissues and passes during the early weeks of life a purely vegetative existence. At three months of age or thereabouts the child is said to "notice" that is to say, it takes cognizance of what comes before it. It follows with the eyes a candle or a Illustration of simple sensation of touch. Arrow represents impression conveyed by sensory nerve to nerve-center in brain. ball of bright yarn, watches for them and associates pleasant sensations with them. It perceives that the candle or the ball of yarn is the cause of an agreeable feeling. This, the conscious recognition of the cause, is Perception. When first a nursing-bottle is placed to its lips, these close down about the nipple and the opera- tion of sucking begins. There is an impression conveyed by the touch and taste organs of the mouth, through corresponding nerves, to the sensory, or special sense, centers in the brain ; from thv,se centers reflected upon motor nerve-centers in the brain, and through motor 16 PSYCHOLOGY. nerves going from the brain to the muscles. Result: the operation of sucking, which is at first a purely re- flex act. Later, the child watches for the bottle of milk, extracts its contents when offered, or helps itself if the bottle is placed in the cradle. There is here Perception : the recognition of the external causes of the sensations which the bottle and its contents furnish. There are necessary to Perception : 1. A nervous mechanism to receive impressions. 2. Sensory nerves, or nerves of special sense, to con- vey impressions. Illustration of visual perception. 3. Nerve-centers in the brain to receive impressions. 4. Consciousness. Perception is made up from a number of distinct per- cepts; as, for example, form, size, color, vibration, density, taste. These individual impressions united, and with the aid of consciousness, form a percept of the object. In order that percepts once acquired may be stored up for future use, there is necessary another mental faculty, which is MEMORY. This is the faculty which enables the re- tention and reproduction in mind of impressions re- ceived. PSYCHOLOGY. 17 Impressions proceed from the different organs of sense to areas of the brain in which they are registered. Memories of percepts are created. Of the function, memory, Scripture writes as follows : "If I were writ- ing a dictionary, I would define memory as that portion of mental life about which everybody has been talking for three thousand years without finding out anything more than anybody of common sense knows before- hand." Bergson, in "An Introduction to Metaphysics," makes use of the vivid expression : "I notice the mem- ories which more or less adhere to these perceptions and interpret them." So much for memory. It is known only, through its manifestations. 1 There are two kinds of Memory : 1. Memory of percepts. 2. Memory of self (Organic Memory). The memory of self (organic memory) permits the registration and storing up of impressions from all 1 During the years of brain evolution, the developmental period of life, memories are being stored constantly. Of many of these, use is made from day to day and every day, others lie dormant and affect conduct only when some special event calls them into activity. Nothing perhaps is com- pletely forgotten while the brain is normal. Even in mental impairment due to age, there is often ability to recall dates and incidents of earlier years when the brain was recording. In advanced age there is apt to develop disease of the arteries and supplying blood-vessels which interferes with the nutri- tion of the brain cells. Current events then are not indelibly registered. The individual cannot remember at noonday what he has read or heard at breakfast time, he lives in the past and cannot utilize experiences of the present as a guide to acting or in conversation. A condition comparable with this is also found in certain organic diseases of the brain as paretic dementia. 2 18 PSYCHOLOGY. parts of our bodies : from the skin, bones, muscles, and internal organs. These are for the most part sensory memories carried originally by inward-conducting (sen- sory) nerves. There are also motor memories origi- nally collected from muscles influenced to action through outward-moving impulses from the brain. Upon this memory-storing the Ego the Personality depends. Sensations such as are here mentioned do not, as a rule, come into consciousness independently; but, taken together in health, they constitute our feel- ing of well-being: our sense of self. In disease we may become, at times, acutely conscious of some or all of them. The development of the personality is ex- tremely interesting. The child at first is unconscious of its own existence, of its own individuality. It refers to itself in the third person : "Johnnie wants it," "Mamie wants it." The Ego I is not present. The child inspects its fingers and toes, as it does that which is held before it, as something foreign to itself. Later, organic sensations proceeding from the fingers and toes and impressing themselves upon the consciousness give to the child the recognition of proprietorship. The organs become part of the child's body. The existence of the child at first seems to be of a dual character. Later, the Ego is formed the personality through sensations proceed- ing from all the organs and tissues of the body and registered in the organic memory. The PERSONALITY is of great interest to those study- ing insanity, for in disease of the mind it is frequently found that alteration in organic sensations has given to the individual an impression of bodily loss or of change in constitution. Disturbance of sensation, in PSYCHOLOGY. . 19 the foot, may lead to the illusion 1 that this member is lost or dead, checking or hindrance of mental oper- ations may lead to the delusion 1 that the mind is under the control of another. Defective elimination from the torpor of the stomach and bowels, causing a metallic taste in the mouth, may occasion the morbid belief that poison has been administered ; inadequacy or impotence in the sexual sphere arising from over- indulgence or indiscretions may be attributed to a "charm" or hypnotic influence exerted by another who has given real or fancied ground for jealousy. 2 Change in the action of the nerves of the skin may occasion the delusion that electricity or some harmful agency is at work upon the body. Sensations, indeed, may be so altered in insanity as to lead to the belief in a double personality. This is not difficult to understand when we call to mind the clod-like, heavy, foreign feeling of a frozen foot, or that of an extremity which has been separated from vascular and nervous connection with the trunk by a tightly constricting elastic band. Here the sensory nerves are blunted, and sensations proceed from the tissues above the affected point. The organic memory may be so vivid in its reproductions as to convey to the soldier the consciousness of the presence of an ampu- tated extremity. 1 See definitions of "illusion" and delusion, pages 45 and 46. 2 Here wise discrimination is necessary on the part of the examiner. An insane delusion is no less a delusion because there may be fundamentally good reason for criticism or dis- trust of the one toward whom it is directed. It is the char- acter or quality of the belief its reasonableness which is significant. 20 PSYCHOLOGY. IMPRESSIONS taken cognizance of, or perceived by, the mind are hoarded by Memory. The process of grouping percepts together (Re-pres- entation Re-collection) by the aid of Memory, to form concepts or ideas, is called IDEATION. Through impress'ons coming into consciousness, primitive notions of size, consistency, odor, taste, etc., are formed. Grouped together, these form a percept of the object in its entirety, and these primitive percepts associated by the aid of memory form concepts or ideas. Illustration: Take an object in the hand; receive all the impressions possible from it through the medium of common sensation and the special senses. There is here a group of impressions coming into consciousness, constituting a percept of the object (Presentation). Remove the object, and associate the different indi- vidual percepts together through the aid of memory. It may still be seen, or heard, or felt. Thus is constituted a concept, or idea, which is a group of percepts repro- duced in memory (Re-presentation Re-collection). On contact with the flame of the candle the child's finger is immediately withdrawn. This, a simple reflex act, is carried on through the sensory nerves, the con- ducting paths of the cord, the ganglia at the base of the brain, and the motor nerves. With this experience of the candle, however, there is registered in perceptive centers the memory of disagreeable sensation. Next confronted with the flame, the child draws back in terror. Associated with the sensory memory are cithers of a visual character which enable the child to identify the lighted candle as the cause of the previous painful experience (Perception, Ideation). Later on, as its PSYCHOLOGY. 21 observation increases, there is a tentative investiga- tion and pleasurable percepts arise from the proximity of the light, Judgment (the higher control) having meantime been set in operation to restrain the child from putting its hand into the flame. Later come the concepts connected with the use of the candle, and from this time all manner of association of concepts and judgments based thereupon may arise. In the first instance the simple reflexes were involved. In Illustration of concept, or idea. Each grape rep- resents the memory of a percept. These united by the stem, ideation, form the concept. the second there come into play simple associations of concepts, and in the latter the higher cerebral func- tions of Reasoning and Judgment. For the second process, the visual perceptive centers in the posterior brain and the conceptual centers in the midbrain come into play; for the third, the higher cerebration, association of concepts to form judgments, there is demanded, in addition to the interaction of the different portions of the brain already mentioned, the action of the forebrain, or the so-called prefrontal lobes. 22 PSYCHOLOGY. REASONING. This faculty is also necessary to the development of the mental life. Reasoning is the asso- ciation of concepts, or ideas, to form a judgment, and the association of judgments to form new judgments. In reasoning, we weigh and compare concepts, or ideas, by their likeness, or unlikeness, their value or worth- lessness out of which grow judgments as to their expediency as applied to acting. Passing along the street of a strange city, I observe banners waving, bunting and floral decorations con- spicuously displayed. The faces of those met wear cheerful expressions. I hear lively airs played by dis- tant bands. Association of these concepts by the aid of memory of previous experiences permits the con- clusion (judgment) that a fete is in progress or about to begin: also the further judgment this time di- rectly applied to acting that if I would see the parade I must move in the direction of the music or at least not in the opposite direction. Dirge-like music, flags at half-staff, the booming of guns, the tramp of marching feet call up the judgment that a military funeral is in progress and the further judgment that "War is hell." A loud-toned bell strikes one two, one two three, a siren whistle peals out, there is a rattling of hoofs on the pavement, bells clang, and a rumble of rapidly moving vehicles is heard. There is a sudden hush in other traffic on the street. Those sitting near me playing cards prick up their ears and count the strokes of the bell, then turn and resume their play all save one. He hurriedly leaves the room. Con- clusion (Judgment) : 1. A fire is in progress. 2. It is in the precinct in which the one resides who has so PSYCHOLOGY. 23 hurriedly made his exit. 3. That my fire insurance expiring today should be renewed. The association of the sound of the deep-toned whistle and the slowing of machinery calls up the judgment that a fog has settled down and instantly there arises the fear of collision unless navigation is carefully conducted. The association may be carried so far that fear and trepidation are lost in speculation upon the size and shape of icebergs and the probable loss of time in the ship's running consequent upon the unexpected incident. Previous concepts connected with the ill-fated Titanic may be revived and a whirl of judgments fully or fragmentarily (according to the degree of expert knowledge one possesses) formed as to the expediency of building steamships of that class, as to the divorcement of practical navigation from business management, and the necessity for complete independence of the ship's captain at sea; as to the practicability of larger and more varied life-saving equipment, as to the claims of the weak and defense- less, and as to the toweringly high quality of American manhood and chivalry displayed without exception in this shocking disaster. Use for illustration, the naturalist's classification of the animal kingdom. A similarity in structure, in that all possess a spinal column, causes large numbers of animals of widely different appearance to be grouped under the designation vertebrates. So of other orders : essential differences in structure separate the mollusks from the articulates, and the articulates from the radiates. To go further, closer anatomical or physio- logical resemblances cause the division of the verte- brate kingdom into families, or subclasses: mammals, 24 PSYCHOLOGY. birds, reptiles, and fishes. This process of weighing, comparing, and measuring is called Reasoning, and the result of the process, Judgment. Associate concepts of compression and steam (ex- panded water). There is called up the concept of force, and a container of metal to supply resistance that the force may be utilized. Judgment : Expanded water confined in a receptacle of steel a boiler exerts great force, and may be used in moving power- ful bodies (locomotives). Again: Compare the idea, or concept, man which involves many percepts of his different attributes with the concept reptile. Judgment: Man is the superior being. Again : One looks out-of-doors upon a cloudy sky. He perceives the absence of sunlight and the direction of the wind ; is conscious of, or perceives, a chilliness. He groups these percepts together, and by the aid of memory reduces them to concepts. There is a re-col- lection of past experiences. He associates the concepts together by reasoning. Result: Judgment, that the day will be unpropitious for a picnic. JUDGMENT : The result of a comparison or associa- tion of concepts, or of the comparison or association of judgments. Let two telegraph-poles be taken as representing each a concept, or idea. Reasoning is the wire that unites the two ; Judgment is the result of the union. Or let each pole represent a judgment. The wire, reasoning, unites the two, the whole forming a new judgment. To recapitulate : Sensation + Consciousness = Percept. PSYCHOLOGY. 25 Percept -f- Percept -f- Memory = Concept. Concept -(- Concept = Judgment, or Judgment + Judgment = New Judgment. The plus sign which stands between the words Per- cept and Memory is the equivalent of Ideation. The plus sign which stands between the words Con- cept and the words Judgment is the equivalent of Reasoning. As before stated, Sensation, Perception, Memory, Ideation, Reasoning, Judgment, enter into the thinking process. If any avenue to the brain is closed, as by congenital deafness or blindness, mental development and mental ability are correspondingly lessened, al- though scientific methods applied in the education of the remaining senses go far to remedy the deficiency. The experience in the case of Helen Keller, congeni- tally blind and deaf; her astonishing mental develop- ment, through education by means of the tactile sense, constitutes an entire book of Psychology. Thought in man is usually, perhaps invariably, con- ducted in words or their visible signs. Let anyone try to think and he will find that he is mentally grouping words together into sentences and that his unspoken idea is framed as if it were to be expressed. The deaf-mute, who has not a vocabulary of words, thinks in visible signs; that is, in gestures which stand for the representatives of ideas. 1 1 See footnote on page 45, and the chapter "Symbolism in Sanity and in Insanity," page 58. 26 PSYCHOLOGY. The Localization of Function in the Brain. The study of cerebral topography is rapidly pro- ducing more and more beneficent results. 1 Since 1870, at which time Hitzig showed, through experiments on the brain of a dog, that co-ordinated movements could be produced by electric irritation of certain definite re- Zones and centers of the lateral aspect of the human cere- brum. (Mills, "Nervous Diseases," J. B. L. Co.) gions of the cortex, and the period, a trifle later, of Ferrier and Munk, who, through irritation and excision of the cortex, mapped out certain regions having to do with definite special senses, knowledge of the subject has been steadily increasing and is becoming more and more accurate. This knowledge has in recent years been greatly augmented by the tremendous advances 1 Surgical experiences in the late war are amply confirm- atory of this. PSYCHOLOGY. 27 made in cerebral surgery through the work of Horsley, of England; Gushing, of America, and others. The best-known area is that of the motor region of the cortex. Mechanical irritation of different parts of this motor area produces co-ordinated movements. From this region motor incitations pass out to centers in the medulla and cord, and are discharged upon the muscles ; and pressure or structural disease in a given locality in this motor area produces loss of power in the group of muscles innervated therefrom. In other areas afe situated the psychical centers of vision, hearing, and smell, and their destruction in- volves a loss of memory of percepts derived through the medium of these special organs. In mental blind- ness there is a lack of recognition of familiar objects, and there may be such failure as to persons with whom one has been on intimate terms. There are all degrees of cortical, visual blindness from the inability to com- prehend the meaning of written and printed words to that extreme, involvement of the psychical centers al- ready mentioned. The occipital lobe and the adjoining area of the parieto-temporal lobe, called the angular gyrus or convolution, contain this visual center. The psychical center for hearing is located in the first and second temporal convolutions. Lower down in the temporal and in nearby portions of the brain are presumably located the centers for taste and smell. One may be mentally deaf notwithstanding the fact that the organs of hearing outside the brain are intact. In a general way the sensory part of the brain is located posteriorly, the motor portion anteriorly. In the latter portion is found the interesting convolution of Broca in which are located the memories for articulate speech. 28 PSYCHOLOGY. Aphasia, inability to remember words and apply them in their proper relation, may be total or partial. The enunciation of a considerable number of words or sen- tences may be possible, or the vocabulary limited to a few, as "yes," "no," and "you." I have had under ob- servation a patient whose sole exclamation is a sound like "ein." This she gave forth with varying inflec- tions and her manner betrayed disgust or reproachful- ness that her communications were not correctly inter- preted. She apparently understood all that was said, but her word-forming power was nil. In this case there was also agraphia, or inability to express thought in written characters. These two conditions, though not necessarily, are commonly associated. One may write and understand written or printed speech when deprived of the use of spoken language. Aphasia due to the lack of word-forming capacity or the loss of object-naming power is not to be con- founded with the inability to articulate distinctly and the gradual loss of speech so common in a certain form of brain disease, paretio dementia. Here the involve- ment affects the motor zone in its entirety, and the resulting impairment is that of ability to co-ordinate muscular action that is to say, to work muscles to- gether. This symptom is called Ataxia. Apraxia is another symptom sometimes associated with aphasia. It is due to the loss of recollection of the uses of ob- jects. Handed a pencil, the patient inserts it in his mouth. He attempts to polish his shoes with a jews- harp and to comb his hair with a hammer. The zone of language is said to comprise three cen- ters and has been enlarged by certain authors to in- clude a conceptual center. Mills says of the zone of PSYCHOLOGY. 29 language that it includes three centers, namely, that for the images of articulation, that for auditory images, and that for visual images. "Each of these centers is situated in the part of the zone of language which ap- proaches most nearly to its corresponding general zone, motor or sensory. The motor center of articulation is in proximity to the psychomotor region, the center of visual images approaches most nearly the general visual zone; and the center of auditory images is in close relation with the general auditory sphere. In this zone of language the center for auditory images is that first evolved and most deeply organized. As a rule, the child's first ideas of language come through hearing; articulate speech is next evolved; the child hears, and it speaks; it learns to repeat the names of persons and objects with which it comes into relations; later, in those who become educated,. a center for the visual images of letters and words is organized, and still later, at least according to some authorities, a center for graphic motor images. The auditory and motor speech centers continue to be for the vast major- ity of people most important constituents of the zone of language." Feeling : Emotion. Were logical order followed, Feeling, or Emotion, the second manifestation of mind, should have been considered previous to thinking, inasmuch as feeling (sensibility) must inevitably precede thinking. The term "feeling" must not be confounded with the sen- sation springing from the special sense of touch. What is understood by "feeling," as the word is here used, is a bundle of mental experiences, some of an agree- 30 PSYCHOLOGY. able, others of a disagreeable, character. The major- ity of concepts are, in some degree, pleasurable or painful that is, there are few which may be classed as entirely neutral: from which some satisfaction, or the reverse, is not derived. To the extent to which ideas are accompanied by pleasurable or painful feel- ings they may be considered emotional. An emotion, therefore, may be defined as an idea accompanied by a feeling of pleasure or pain. As the feeling preponderates the idea grows less and less dis- tinct until almost overshadowed. The word "Emo- tion" comes from two Latin words: e, from, and motio, motion. In the emotions lie that which moves to action. Desire, loathing, mirth, sadness, affection, hate, faith, fear find through the emotions their varied means of expression. Apart from the vocal attuning which the feelings occasion in speech there is a separate physical language of the emotions. Witness the blanched face, the contracted muscles, the dilated pupils, and protruding eyes of Fear; the flushed face and swelling throat of Rage; the anxious or relaxed and downcast physiognomy of Mental Depression ; the bright eye, the clapping hands, and laughing expres- sion of Pleasure ; the cooing sound of Satisfaction. The emotions lie close to the organic (bodily) func- tions. They find their quick reflex in the muscular expressions of fright, pleasure, despair, and comfort, already referred to, as the idea of unemotional char- acter finds its slower expression by the organs of speech or voluntary action. Displaying in themselves the earliest states of consciousness, the emotions are among the first to suffer in mental disease, as will be hereafter shown. The individual breaking down with PSYCHOLOGY. 31 Cefivic/u. Co*, Diagrammatic representation of the Sympa- thetic Nervous System. (Modified from Meyer and Gottlieb.) 32 PSYCHOLOGY. mental disease reacts to painful or pleasurable impres- sions with an unaccustomed intensity. Emotional states are accompanied by certain phe- nomena referable to the action of the so-called sym- pathetic nervous system. This consists of a double chain of ganglia extending from the base of the brain along the sides of the spinal column to its tip and of certain ganglia scattered among the organs of the chest, abdomen, and pelvis. Fibers from the sym- pathetic are distributed throughout the body generally ; indeed, more generally perhaps than those of the cere- bro-spinal system. Their function seems to be emotive and nutritive. They go to the stomach and intestines. (Everybody knows that bad news arrests the digestive processes.) They are distributed abundantly in the heart. (We speak of heart-sickness, of heart-break.) They control the caliber of the blood-vessels. (Hence the flush of embarrassment, the pallor of rage.) They are distributed to the radiating surface of the iris (whence comes the pupillary dilatation of fear). They supply the kidneys (the increase of whose function is so notably affected through fear). They govern other glandular secretions. (Under emotional stress the mouth grows dry and parched, and in rage the nursing mother's milk becomes unfit food for the offspring.) Emotional states are attended by characteristic mus- cular movements. The teeth are set in anger, the eyes opened widely in deprecation, the brow corrugated in pain, the nose elevated in contempt, the head uncon- sciously oscillated under humiliating recollections. The shrug which accompanies doubt or misgiving, the atti- tudes of prayer, of pleading, of remorse, of prediction, the wringing of the hands in despair, the clapping in PSYCHOLOGY. 33 appreciation, are universal modes of emotional expres- sion. Among members of the unfortunately designated "brute creation" the horse neighs ; the cat purrs with satisfaction; the dog wags his tail in pleasure, lowers his ears in chagrin, and displays his teeth when threat- ening. In the feathered family the peacock is notori- ous for the exhibition of vanity, the cock for strutting in triumph, the goose for shallow defiance. 1 1 Four decades or thereabouts have rolled 'round since Dr. R. M. Bucke of London, Ontario, published a thoughtful thesis in book form, entitled "Man's Moral Nature." In it the opinion was expressed that the moral nature (limited by the author to the capacity for love, hate, faith, and fear) was located in the sympathetic nervous system. Muscular and vascular phenomena and deviation from the usual in glandular and other functions under emotional stress were cited in development of the theory. Much has been written during the years 1914 to 1919 of the morale of armies and a peculiar nervous affection attributed to shock from explosives has been described. The morale of a soldier group is determined by the reaction of its in- dividual constituents to the exigencies of the momentary situation. Love of country and family, faith in the justice of the cause in which they are engaged, desire for (love of) distinction and promotion, hate of the enemy and all his works, dread (fear) of the exhibition of cowardice, fear of filth, vermin, contagion, death, mutilation, imprisonment, starvation, and frightfulness, are the conflicting emotjpns which surge through the mind. Preponderance of hate of the enemy, love of country, and faith in the cause go far to determine courage and constancy. Domination of fear of the results of warfare to himself, his family, or country under- mine morale and weaken both offensive and resistance. The symptoms of an infirmity, the current name for which is disapproved by the Mental Hygiene Committee,- are mainly those in close association with the sympathetic nervous system. The patient is fearful, perhaps hallucinated, he cannot "collect" 3 34 . PSYCHOLOGY. The relation of emotion in the abstract to muscular expression is profitable for study, not only because of its psychological interest, but because of its practical bearing upon human conduct. Clench the fist and shut the teeth firmly and there immediately arises in con- sciousness a sense of resentment, of pugnacity. Draw down the corners of the' mouth and the emotional tone takes on a shade of depression. Elevate them and a pleasurable sensation follows. This has an important relation to mental development. To cultivate the mus- cular play that accompanies pleasurable states must in- evitably affect the disposition of the individual in a favorable manner. Apropos of this, one patient who was highly tearful was advised to assume a happy expression and this couplet was quoted to him: "Laugh and the world laughs with you, Weep and you weep alone." himself, he has "cold feet," metaphorically and literally. From wide swinging of the emotional pendulum bizarre move- ments result and his walk is the veriest incoherence of mus- cular expression. He suffers from heart fluttering, tremulous- ness and shivering, from bowel fluxions and bladder incom- petence : shows pallor and flushings, goose pimples or profuse perspiration. He starts at every sound. There is frequently disturbance in the sexual sphere extreme eroticism and sus- cep^ibility. In brief, the inhibitory (checking) control is im- paired or lost through conflicting emotions and the output is hysterical in the largest sense. It is plain that the functions chiefly affected are those of organs liberally supplied from the sympathetic and the simi- larity of moral and morale becomes distinctly more than orthographical. Definite psychologic and somatic relations between the* words are established and Dr. Bucke's declaration is apparently more solidly based than in the long ago days in which it was made. PSYCHOLOGY. 35 "That's all very well," he said, "but it's written dif- ferent nowadays. Now it is 'Weep and the world laughs at you.' " Sitting in my room, distant from the window, memo- ries connected with the automobile are revived by the auditory percept "honk honk." The sound of hoofs upon the pavement perceived at the same time is sud- denly arrested, screams are heard, and there is a crash- ing noise. I am re-minded (memory concepts re-col- lected) that one of my family expected to drive out at this hour. I am impressed that the sound of hoofs resembled those of my peculiarly gaited horse and that the "honk honk" proceeded from a horn an auxiliary to the automobile of a friend. Associating concepts by reasoning, the judgment is formed that there has been an accident and the emotion (Feeling) of fear inspires desire to investigate. I will to verify or dis- prove the judgment by adding new visual percepts, and hastily make my way to the window. There are here present Percepts and percept association, Percept association with memory aid (Ideation), Concept association (Reasoning), Judgments, the result of concept association, Emotion inspired by concept association, and Volition prompted thereby. Feelings call forth desire. DESIRE forms the con- necting link between feeling and that which is next to be considered, viz. : Volition. VOLITION may be defined as action prompted by desire and representing choice. Thus, it is to be dis- 36 PSYCHOLOGY. tinguished from all other forms of action not so prompted: from simple reflex action, already spoken of, and from higher reflex (automatic) action. In speaking of perception in the child, reference was made to the operation of taking food. At first this was an unconscious and purely reflex act. There was trans- mitted to the child a nervous mechanism that, excited by the presence of the nipple to the lips, occasioned the muscular act of sucking. Through inherited trans- mission the child was endowed with this simple instinc- tive power. Through ages the nervous mechanism in use in the appropriation of food has acted in definite ways, and nervous channels, so to speak, have resulted. Sensory impulses have traveled from lips and tongue to the cerebral sensory centers; they have been re- flected upon motor centers, and traveled back along the motor nerves to groups of muscles about the tongue and throat. Impressions registered in the organic memory, and action prompted thereby have enabled the appropriation of food to go on until such time as desire impels and voluntary action permits the gratifi- cation of appetite. This constitutes one of the few inheritances of the human infant. The organic memory of pain and the reflex act of crying (the expression of pain in the absence of con- scious suffering) is another inherited quality. It is the organic sensation of hunger, which expresses the de- mand on the part of the system for food, that impels to the taking of food before there is conscious recogni- tion on the part of the child of its own wants or the ability to gratify them. Later on, voluntary action action prompted by desire and determined by choice appears. Compare the child with the chick, which, PSYCHOLOGY. 37 immediately after emerging from the shell, walks about in search of food and picks it up, takes refuge under its mother's wing when called, or flees from the cat, and displays, from the first, adaptabilities and powers which, in the child, are the result of education. Mental development, except under rare circumstances, however, goes little further in the chick. It is, in all essential respects, the mature animal. It is through prolonging the period of infancy that evolution has brought about in mankind the capacity for high mental development. Again, certain acts which the child laboriously and tediously acquires become, by the assistance of the or- ganie memory, automatic in their character. Take the illustration of walking: It is in the child the result of slow education of the nervous centers. Behind it there is at first a feeling of desire to walk ; then comes the education of the voluntary muscles of locomotion. Eventually, by means of the nervous channels estab- lished in the brain and cord, walking is carried on automatically, the initiation of the movement only being voluntary. The child walks, runs, and turns about, all without the conscious exercise of volition. Contact with the ground, the sensory impulse proceed- ing by the way of the spinal cord to the brain, its recep- tion by the sensory centers, its reflection upon the motor centers, and through the motor nerves to the muscles concerned in the act, are the steps in the process. So of self -defensive acts. At first the child re- quires to be protected from all manner of harm. Later, through education, it acquires self-defensive ability and involuntarily shields itself from that which 38 PSYCHOLOGY. threatens. One is conscious of averting danger, or of taking self-defensive measures, oftentimes after the act is completed. He raises the arm to ward off a blow and sensing (not perceiving) a stumble he throws him- self from the saddle and alights on his feet as the horse falls. All sorts of habits of life are thus formed. Winding the watch before retiring frequently takes place without consciousness. The act of locking or unlocking a door is done automatically. Piano-playing, an accomplishment tediously acquired, is finally carried 1 Illustration of volition. on through the organic memory without appreciable voluntary effort except in the act at its beginning. These are higher cerebral reflex acts. The Higher Volition, like the other faculties of mind, is a plant of slow growth, and involves discrimi- nation, comparison, weighing of ideas, and judgment as to the best course to pursue. It is difficult to deter- mine when the child first exercises volition. The choosing between that which is sweet and that which is without marked flavor, but better for his needs, is, to be sure, an action prompted by desire ; but the higher volition implies discrimination between that which is profitable and that which is unprofitable. Cultivation of the reasoning and judgment are necessary to this. PSYCHOLOGY. 39 The education of the will is most important to the future of the child. The matured judgment places an inhibition a restraining influence upon the actions, that decision between that which is ultimately good and that which is immediately gratifying may result. It may be a source of present satisfaction to smite in the face one who has injured me, but the higher volition restrains the act. The law rightly makes distinction between impulsive acts and those prompted by deliberation and choice One in the heat of passion kills another who has seri- ously wronged him. Here the judgment was obscured by the emotional feeling, and a muscular act resulting in death occurred. On the contrary, brooding over a wrong, one deliberately decides to kill, and carries his plan into execution. In the one case the act was semi- instinctive, self-defensive in a way. It was prompted by sudden resentment, and the emotion obscured the judgment. Result: manslaughter. In the other case there was a deliberate choosing, a careful adaptation of means to ends, a judgment and a will to kill. This was murder. It is important to distinguish Simple Reflex Acts, Higher Reflex Acts, Volitional Acts, and Inhibitory Acts (a variety of the volitional). The first Simple Reflex Acts are instinctive: as the involuntary withdrawal from contact with that which is painful; winking; breathing. The second Higher Reflex Acts were originally voluntarily acquired learned but, once learned, go on, in a measure, automatically, the volition, if exer- 40 PSYCHOLOGY. cised at all, merely initiating the movement: as the act of walking. Volitional Acts are those which spring from desire and represent choice : as the putting on of rubbers in wet weather, to protect health. Inhibitory Acts a variety of volitional acts are those which check the immediate response to desire and impulsion, and introduce a restraining influence a "will not to do," so to speak. The higher volitional and inhibitory acts imply the exercise of judgment. LIMITATIONS OF THE WILL. 1. The will has no prolonged power over involuntary muscles. Let one try to stop breathing, and demon- strate this for himself. 2. The will does not control movements which have not been acquired by practice. One may satisfy him- self of the truth of this in his first bicycle ride. 3. Painful thoughts cannot be dismissed from the mind by an effort of the will. They must be sup- planted and crowded out by introducing others. . Recapitulation. SUBJECT THE PENCIL. Sensation (visual) -{- consciousness = Percept of Color. Sensation (touch) -\- consciousness = Percept of Surface. Sensation (touch and vision or either) -f- conscious- ness = Percept of Form. , Sensation (muscular) + consciousness = Percept of Density or Resistance. PSYCHOLOGY. 41 Percepts of Color, Surface, Form, Density + Mem- ory = Concept or Idea of the Pencil. Assembling these is called Ideation. SUBJECT THE PAPER. Sensation (visual) -+- consciousness = Percept of Color. Sensation (touch) -f- consciousness = Percept of Surface. Sensation (touch and visual, or either) -f- con- sciousness = Percept of Form. Sensation (muscular) -(- consciousness = Percept of Density or Resistance. Percepts of Color -+- Form + Surface -f- Density -(- Memory = Concept or Idea of Paper. Process of association of these is called Ideation. Concept of Paper -|- Concept of Pencil = Concept of Writing. The process of assembling is a larger Ideation. Association of Concepts of Writing and Obligation = Judgment to answer correspondence. The process is called Reasoning. Association of concepts of pencil and writing on fragrant paper, which introduces another sensory per- cept, results in judgment to write a love letter. (Here a pleasant emotion is a strong determining influence). Associations of concepts of writing and pencil and fragrant paper with further memory ad- irixture recall concepts connected with the fountain pen and these incorporated, a new judgment follows that the fountain pen is preferable to the pencil. Desire prompts and reasoning establishes judgment to write and judgment to use the fountain pen which 42 PSYCHOLOGY. are associated in the new judgment to proceed to the exercise of volition will in extending an invitation to attend a ball, but the will to do is checked by the color percept of black on the border of the cor- respondent's paper, calling up the concept of mourn- ing: The emotion of sorrow prompts judgment to withhold the invitation. Desire has set reasoning in motion and determined judgment: judgment resulted in volition, and volition placed muscles in action, but another judgment has interfered. This has been ac- companied by an emotion which checks (inhibitory control will not to do) and the pen ceases activity. Desire and resultant reasoning determine the judgment to write a proposal of marriage and will sets the muscles controlling the fountain pen in opera- tion. Then comes an emotion, fear, as to how the letter may be received. This prompts a counter- judgment and inhibition (the will not to do) arrests the pen. The concepts of obligation, of good-will, of reci- procity, of national honor are associated by reasoning in a judgment to sign a treaty. Concepts of indignation and contempt and resent- ment determined by violation of the contract associa- ted by reasoning form the judgment to war which judgment may be checked (inhibited) by a counter- judgment resulting from a state of unpreparedness. With concepts of writing may be associated con- cepts: First, concerning the fountain pen gutta- percha, gold, sword (pen mightier than) war, ink, blackness, despair, dishonor, fog, clearness (in writ- ing) light, sunshine, God's Providence: Second, con- cerning the pencil wood, rubber, elasticity, curiosity PSYCHOLOGY. 43 (rubber-neck), lead, heaviness, point, sharpness, cynicism. With the Concept of paper, may be woodpulp, soft- ness (pulp), susceptibility, love, hate, regret, treaties, sealing wax, war, famine, preparedness, honor, fright- fulness, submarines, mines (marine), mines (land), coal, heat, light, charity (Let your light shine), tor- pedoes, Fourth of July, Declaration of Independence, dependence, reciprocity, the square deal, square (car- pentry, masonry) deal (business, cards, bridge), bridgehead, assault, prisoners, brutality, optimism (Prisoners of Hope), so on to infinity. Such a jumble when . inhibitory control and self-direction is impossible because of insanity, is called "flight of ideas." General Considerations. All of the foregoing has its bearing upon the study of mental disease. In insanity any or all of the func- tions of the mind may be disturbed. Any or all of the elemental processes of sensation, perception, ideation, reasoning, judgment, memory, may be impaired. Upon the integrity of these ele- mental processes and those of emotion and volition de- pends our normal relation to our environment, and it is interesting to consider from a psychological standpoint in what manner and to what degree these elemental processes are disturbed in different states of mental ex- citement, depression, or weakness. SENSATION may be impaired or lost. The special senses of taste and smell may be so much at fault that the vilest substances placed in the mouth do not excite disgust. In such a case PERCEPTION also fails. Faulty 44 PSYCHOLOGY. perception may further manifest itself in Hallucina- tions and Illusions. Sensation is altered or lost in hysteria, in epilepti- form states, in pseudoparetic states dependent upon syphilis and alcoholism, and in the various forms of dementia. It is a matter of experience that sensation may travel more slowly and be less acute in the men- tally diseased than in the healthy individual. Sensation is impaired in apathetic conditions, is increased in maniacal states, in delirious states, and in the frenzied periods accompanying certain forms of manic-de- pressive insanity. Perception is perverted in certain manic-depressive states, is delayed in apathetic states, is transformed into hallucinatory states in acute excitement and de- pression, in different forms of delirium, in paranoia, in dementia praecox, and in organic brain disease, but may be outwardly undisturbed in the recurrent type of manic-depressive insanity. A Hallucination is a false perception without an ob- jective reality. Example : One, looking upon the bare floor, fancies he sees a snake. There is nothing what- ever upon the floor which could lead to that perception. He is suffering from a visual Hallucination. One looks upon a carpet with bright figures and irregular tracings, and sees in the bright figures birds of brilliant plumage, and in the tracings of duller colors snakes or rats. He is suffering from an Illusion, that is, a false perception with an objective reality. He hears the sound of steam escaping from the radiator, and, in this sound, the voice of some one threatening to kill him; in the ticking of his watch he hears commands ; in the locomotive whistle he per- PSYCHOLOGY. 45 ceives calls and shrieks. He is suffering from illusions of hearing. He hears a cry when all is still; he has an auditory hallucination. Thus, in smell, taste, touch, and the muscular sense hallucinations and illusions may develop. The weight of the bedclothes may give the impression, through the muscular Sense, of a heavy load ; or one may fancy himself exerting great muscu- lar strength, may even perspire and become manifestly exhausted through efforts to sustain bodies which in fancy are burdening him, while, in fact, he is entirely free from any weight or pressure. Hallucinations of hearing exist in insane patients who have deafness, acquired; of vision, in those who have become blind : there could be no better illustra- tion of the fact that we hear and see with the brain the mind not with the eye and ear. The inference follows that hallucinations of hearing or vision in one congenitally deaf or blind would be impossible the cerebral centers which preside over these senses in health never having been in action. No true concep- tion of sound can exist in one congenitally deaf, or of color in one totally blind from birth. Consequently no hallucination can be present. 1 1 In the Journal of Mental Science for July, 1895, an inter- esting account is given of the hallucinations of a deaf para- noiac. The case reported by Dr. Cramer to the Psychiatric Association at Berlin is, in brief, as follows: He was 37 years old and had been born deaf; but had been educated and learned to be a portrait-painter. When admitted to the asylum at Eberswalde he was much excited and violent "He was very suspicious, not at all communicative, and very diffi- cult to handle. In about ten months he began to improve and engaged in outdoor work. A year afterward he again resumed his painting and was willing to converse. Dr. Cramer framed a number of questions which the deaf man 46 PSYCHOLOGY. Hallucinations and illusions give rise to Delusions. Hallucinations may be present in the mind of one not insane. As long as they are corrected by the reasoning and judgment they do not amount to delusions, j Be- lieved in, however, and present because of a diseased condition, they become delusions. A Delusion, therefore, is a false belief due to disease. The qualification "due to disease" is introduced be- cause there are multitudes of false beliefs in the world not due to disease, but to faulty education, as the beliefs in witchcraft, Divine Right of Kings, satanic possession, the evil eye, the visitation of ghosts, Mary Baker Eddyism, 1 etc. In estimating the importance answered in writing. Instead of hallucinations of hearing, for he could not hear, he imagined that communications were made to him by the ordinary signs used by the dumb, and through the words which he had been taught to utter by muscular exercises of the mouth and throat, and also by studying the motions of the lips in others. In these ways he thought that obscure ideas were introduced to his mind. Cramer took occasion to observe that it was an error to believe that in all our thinking heard words are used. In this he is convinced that there are great differences, some even transacting thought through the acoustic form of words, others through the re- vival of images formed from the movements of the organs of speech or the sensation of accomplished muscular efforts." i , 111., February 23. Mrs. died here a few days ago after a brief illness of inflammation of the bowels. She and her husband and other members of the family were Christian scientists. An attempt was made to cure Mrs. by prayer and other practices usually resorted to by members of that faith before summoning a regular physician. The physician was called too late to be able to render any assistance. It is thought by the neighbors and friends of the deceased that the woman could have been saved if medical aid had been summoned sooner. Press Report. PSYCHOLOGY. 47 of a false belief as bearing upon the mental state of the subject, it is necessary to take into consideration his natural habits of thought, his previous education and mode of life. \A philosopher suddenly expressing a belief in witches might be justly regarded as having an insane delusion. It would not be safe to conclude, however, in the case of an illiterate Southern negro, that an expression of belief in witchcraft implied insanity. 1 A venerable priest ministering to the necessities of the members of a fast-disappearing tribe of Indians, on the lower St. Lawrence, told me of unique methods formerly in vogue among them for overcoming the evil spirit "Wendigo" supposed to possess the body of one insane and eat out the souls of others. It was the aim of the Indians to lose in the woods or otherwise In connection with the influenza epidemic the directors of the "Mother" Christian Science Church here announce that the "mind is a source of contagion" and that "ailments can contaminate only as diseased images are held before the thought and paraded before excited imagination preliminary to having them expressed on the body through fear and apprehension." Boston, Oct. 7, 1918, Correspondence Phil- adelphia Public Ledger. 1 A young woman named Lynch, a light-skinned negress, who resides in a cottage in the suburbs of Washington, is causing a stir hereabouts, for she is suspected of being a witch. The charge comes directly from Hannah Johnson, an- other negress, who claims the Lynch woman cast a spell upon her, stealing her sight. The only direct evidence is merely circumstantial. The Johnson woman suddenly has gone blind. She blames the light-skinned negress for her misfor- tune and has preferred charges of witchcraft, which the superstitious negroes of the community are commencing to believe. Detroit Free Press, April 20, 1913. 48 PSYCHOLOGY. dispose of one afflicted with a mental infirmity. On one occasion the priest heard by chance of a puerperal woman suffering from mania. Approaching her cabin about which many "braves" were standing, he heard the words "the cure is coming." The reason for the warning was soon apparent. Inside the cabin he dis- covered the Indian woman bound to a chair placed back up and in a sloping position. Round her neck was a cord which extended through a chink in the rear wall of the cabin. At the other end of this cord there had been relays of Indians, who made it taut from time to time. The priest extricated the squaw from her perilous position, soothed and cared for her. Not long after, however, with the characteristic perversity of one partially appreciating the reason for the atten- tion her neighbors had bestowed and to the end defiant, she exclaimed: "Now I will eat your hearts out." The same expression from two different sources may be, in the one instance the result of ignorance or viciousness, in the other due to a delusion. 1 Thus, the 1 Belief in an insane person's delusion may be held and acted upon by the ignorant. The investigation in the year 1884 of a group of cases concerning which I was called, with two other physicians, to advise the authorities, revealed a singular epidemic of hys- terical excitement proceeding from the insane delusions of one member of a household of fifteen representing three generations. In a squalid hut in the country these people had assembled. The fire in a stove red hot had been con- stantly replenished day and night. Through crevices and windows silver bullets had been fired at intervals by the dis- tracted occupants of the cabin. They had placed forks and steel in the windows. By pricking, flagellating, and grue- some noises they had kept each other awake for a period of about seventy-two hours. They had cut small pieces from the PSYCHOLOGY. 49 denunciation of religious orders by a blatant anarchist might be disregarded as having no bearing, neces- sarily, on his mental condition, while allegations of misdoing in such orders coming from one identified with and theretofore sentimentally interested in them might furnish excellent ground for the suspicion that his mental operations were disturbed. For example, while it is by no means beyond belief that a bishop may be corrupt and licentious and because of these failings tolerant of the transgressions of priests in his diocese, or that the sister superior in charge of a hospital may be addicted to drink or the use of opium, it would be extraordinary if these charges were publicly made by a priest against his bishop, his brother priests, and the fingers and toes of one (her of the original delusion) and promoted continuous bleeding, believing that if it ceased witch possession would ensue. Her arms and legs were ex- coriated from the friction administered. In hurried excur- sions out of the cabin (which was maintained in a state of veritable siege) they had cut off the tails of their horses and slit the ears of their cattle. A physician summoned, I be- lieve, by neighbors, had been attacked and wounded by a knife in the hands of one of the frantic females. A neighbor de- clared "They had been racing through the woods. They would shoot and then race as if in pursuit of something, with dogs barking and men screaming." One of the family related that the father was in a sinking spell. They held his watch for a few minutes, and then laid it on the child's fore- head. As soon as this was done he was "scared to death" and immediately had a fit. While the watch was on the child's head the father had fits, and when the father had it in his possession the child had fits. The husband of one was suspected of being the witch. A sister advised the wife that she "take some breast milk, put it in a bottle, put five needles and five pins in it, and put it on the stove, and if there was any such thing as deviltry, it would make him sick." He 4 50 PSYCHOLOGY. head of a nursing order ; and while freedom of speech is an inborn right of the American citizen, it is difficult to believe that one brought up under the rigid disci- pline of the priesthood could in his sober senses refer to ecclesiasticism as "akin to diabolism." Such ex- pressions from such a source would be strongly indic- ative of departure from the normal standard of think- ing, feeling, and acting. At the same time I have known physicians who, carried away by the logic, the apparent sincerity, the beautiful diction, and the con- tinuity of narrative, have failed to discover anything insane in allegations like these, and have ignored glar- ing inconsistencies in a story because of the forceful language in which it was told. In cases of manic-depressive insanity of the recur- came home sick that night. He was also suspected of poison- ing tobacco, the remains of which the family placed in the stove. After it was burned, he was taken with trembling and had to go to bed. The entire household was imprisoned temporarily, and the insane sister, whose delusions had influenced the remaining members, as well as the one who committed the assault with the knife, was eventually placed in an institution for the in- sane. The maternal grandmother of these patients was an epileptic, the maternal grandfather a drunkard, the father gloomy and morose. The mother was of congenitally feeble mentality, as were all of her offspring. The insane daughter had suffered from two attacks of depression, was subse- quently married, and on the birth of a child became again morbid. She was taken to this hovel which the parents oc- cupied. There, in consequence of the sudden death from epilepsy of a niece, she developed the delusion that the house- hold was bewitched. She had hallucinations of smell, taste, and hearing, and fancied herself suffocating. The phenomena were accepted by the others as the result of witchcraft, and the hysteric infection became general. PSYCHOLOGY. 51 rent type, the physician's services are oftenest in de- mand during the excited period. The conduct of the patient is mischievous and trying. He seems actuated by the spirit of evil, and goes out of his way to make trouble for his relatives and neighbors. He places wrong construction upon innocent conduct and re- marks, he carries tales from one to another, and em- bellishes them with satanic ingenuity, just keeping within the bounds of possible truth. Egotism, self- sufficiency, and intolerance are displayed in language and lineament, but such patients are so clever that it is often impossible to extract definite delusions in ordinary conversation. Here there is also danger of being deceived by externals. The patient makes all sorts of reasonable explanations of erratic and insane conduct, he alleges cruelty and abuse as causes for out- bursts of ill-feeling or resentment. He claims there is conspiracy to deprive him of his property. Toward his relatives, to whom he ascribes unworthy motives, he displays a subtle ingenuity in making trouble. With the medical examiner he conceals, evades, and covers up, and in court he may possibly conduct his own case to the witnesses' very great discomfiture. In the con- dition of depression, however, he is remorseful for incidents of excitement, and is introspective and self- depreciatory. Different degrees of disturbance of REASONING and JUDGMENT may occur, dependent upon the form of men- tal disease encountered. The existence of delusions implies morbid reasoning and judgment. Delusions may have their origin in false perceptions and the at- tempts to explain painful or pleasurable sensations. Reasoning in mental disease is not always illogical. It 52 PSYCHOLOGY. may be fairly correct and from false premises as in paranoia, or be entirely correct concerning everything apart from the individual as in the depressed form of manic-depressive insanity. Reasoning and judgment are disturbed in delirious and maniacal states, and are slowly impaired and lost in the dementias, particularly those of organic form. IDEATION is slow in depression, in the dementias, in different forms of organic brain disease, and in the later stages of alcoholism and opium intoxication. It is quickened in the early stages of opium taking, alco- holic intoxication, and in all forms of maniacal excite- ment. In acute maniacal states it is often so very much quickened that incoherence results ; this is due to the rapid change of concepts and the hurried speech necessary to their expression. In manic-depressive insanity (recurrent type) during the excited period it may be unduly active. The MEMORY may be at fault, both in the recollec- tion of percepts and in the registration of organic sen- sations, as heretofore mentioned in connection with the personality. The memory is confused or may be temporarily ob- literated in maniacal states, may be undisturbed in those of depression, is lively in paranoia, and impaired and finally abolished in various forms of organic brain disease and in the senile insanities. The existence of serious memory defect is always to be viewed with alarm. In dementia from senile causes, as is well known, there may be fairly accurate memory for re- mote events, but none for those of recent occurrence. The EMOTIONS feelings may be at fault. As pre- viously mentioned, disturbance of the emotions is an PSYCHOLOGY. 53 early manifestation of mental disease in many of its forms. In the graver forms of insanity, associated with nervous degeneration, the HIGHER REFLEXES (the co- ordination) are disturbed. VOLITION, which in conditions of sanity is checked and governed by the judgment, may be abolished or very much impaired. Examples : The irregular mus- cular movements, shifting glance, and inattentiveness in maniacal excitement ; the unwillingness to put forth muscular effort in morbid depression. The natural expression of volition depends upon attention and free association of concepts. 1. Inattentiveness, Incoherence, Flight of Ideas, V ' erbigeration, Stercotypy. The ability to concentrate attention is impaired to a greater or less extent in all forms of mental disease. In those in which the dominating emotional note is acutely painful, the lack of ability arises from the feel- ing that nothing is worth while, from quickly oncoming fatigue, from preoccupation with what is going on within, from agitation over distressing concepts. In other states of depression with emotional reduction, it is due to apathy, dullness, or indifference. In delirium, in maniacal states, and in those conditions where pro- nounced confusion exists attentiveness may be but momentary and inability to concentrate due to the interplay of disordered and unrelated concepts, any incidental auditory, visual, or tactile impression calling faintly into being some concept, which immediately finds expression in speech. The sound of the final syllable of, or some determining word of, a sentence suggests another related by association, this in turn 54 PSYCHOLOGY. another, and so on to chaos in expression (incoher- ence), or concept association calls forth entire sen- tences of longer or shorter length, distantly related, but without close dependence and leading nowhither (flight of ideas). Or the presence of words of similar sound determines repetition again and again of some sentence or fragment of a sentence, or meaningless rhyme. When having to do with v/ord repetition, this is called verbigeration. 1 A similar symptom, stereotypy, 1 may also display it- self in the motor sphere of speech, and elsewhere, as in rigidity of certain groups of muscles, purposeless movements of a rhythmical character, peculiar attitudes in walking, and resistance to the natural tendencies of muscular expression. In paranoia and certain para- noid states inattentiveness may arise from the feeling on the part of the individual of the superiority of his own outgivings to those of other people and impatience in listening to what he regards unimportant and in- consequential. 2. Pressure of Activity, Retardation, Opposition, Negativism. Natural response to impressions from without will necessarily be altered or impaired more or less in cor- respondence with the degree in which fixation of at- tention is possible. In certain cases reflex is slow and a considerable interval elapses between interrogatory and reply, or suggestion and response. This symptom 1 1 am aware that these terms have been employed in a less restricted signification, but it seems more logical to me to limit the application of verbigeration to the repetition of the same word or of words of similar sound; stereotypy, to sentence repetition and to muscular movements of the same character made again and again without variation. PSYCHOLOGY. 55 Seven minutes of ten. I hear that voice. I hear that voice. I hear that voice. I hear that voice. Take nurse from hall. Take nurse from hall. Take nurse from hall. Take nurse from hall. My mother is safe My mother is safe My mother is safe My mother is safe Some one out side. Some one out side. Some one out side. Some one out side. I am in pain She will not go I am in pain She will not go I am in pain She will not go I am in pain She will not go I am in pain She will not go I am in pain She will not go I am in pain She will not go I am in pain She will not go I am in pain She will not go I am in pain She will not go We are all God's children. Please please tell to come over right away. Please please please please. Illustrations of stereotypy. 56 PSYCHOLOGY. is known as retardation and is usually, perhaps in- variably, encountered in the depressed periods of manic-depressive insanity. In other cases response may be sudden and intense and moved by impressions from without, the pressure of activity from within ; also a symptom of manic-depressive insanity (the ex- cited phase) may be augmented. Response to suggestion to dress or disrobe, to rise or retire, to take food or receive treatment, may fail through fear of poison or personal injury, through sluggishness of the mental reflexes (retardation), through preoccupation with delusions or bizarre con- cepts, or through resistance to the will of others and definite determination upon a contrary course. It is important to differentiate the opposition to taking food or receiving care displayed by a patient fearful of in- jury (a manic-depressive case, for example) from the so-called negativism a characteristic symptom of de- mentia prsecox in which the patient not only opposes, but performs acts directly contrary to those suggested. Attempts to insert his arm in the sleeve of his coat are met by persistent tugging at the free end of the sleeve; to remove the coat, by his tightly holding the two sides together. Asked to lie upon the right side, he turns to the left; given an enema, he forcibly re- strains its operation until apart from the conveniences of the toilet room, or, indeed, ensconced in bed. He voluntarily refrains from emptying the bladder. There is predilection for the beds, clothing, and furnishings belonging to his neighbors and antagonism toward those provided for his own use. In closing this chapter, it seems desirable to empha- size the fact that, although ideation, reasoning, judg- PSYCHOLOGY. 57 ment, memory, volition, and emotional control, any or all, may be impaired in insanity, it by no means fol- lows that insight into the condition is invariably lack- ing on the part of the patient. Certain cases of manic- depressive insanity are conscious of the existence of unwonted exaltation and respond to some extent to suggestion to hold morbid impulses in check. Not in- frequently appreciating the oncoming of lack of self- control, they avail themselves of opportunities offered for hospital or sanitarium care. In depressed periods there is often exaggerated appreciation of the condi- tion and much self-disparagement because of the con- sciousness of ineptitude and worthlessness. Presenile and involutional cases entertain lively fears of "going insane," meaning by this that the patient anticipates his present mental disability will go over into complete lack of consciousness of his surroundings and absence of 'self -control. Admission of the fact of insane con- duct during a previous attack is often in evidence although the patient may deny present disorder in thinking or acting. I have known a dementia praecox patient during a semilucid period to aver he had "always been insane." In two cases of advanced paretic dementia there was lively recognition on the part of the afflicted individuals of the hopelessness of outlook and, in one of these, persistent suicidal deter- mination because of the gloomy view. Insight is rare, however, in the latter class of cases, is notably absent in true paranoia, and can rarely be determined where there is marked deterioration in intellect, as in ad- vanced cases of dementia praecox. PART II. SYMBOLISM IN SANITY AND IN INSANITY. THINKING is conducted for the most part, if not wholly, in words or in their visible signs, visible signs standing for individual words or comprising whole sentences, as, for example, the shrug of the shoulders in dubiety or deprecation, movements of the head in negation or affirmation, and the muscular expressions used as means of communication by the dumb. The trend of thinking and expression is with great fre- quency determined through ocular percepts, and .the realm of object symbolism is far more extensive than the individual is aware until he turns attention directly to the subject. From every object visually examined springs a con- cept more or less perfectly defined, or an emotion directly related to its physical properties, its corre- spondences, its uses, its origin, or its value, as well as many an indirectly related concept which its form, its purpose, its resemblances, bring into being. Every object in nature is in a poetic sense endowed with the instincts, capacities, and sentiments of the human family, and the terms descriptive of regional and special anatomy, or physiological and psychological processes, are transferred to inanimate objects. The oak suggests sturdiness, ruggedness, and strength of character. It has limbs, trunk, and heart. A fellow- (58) SYMBOLISM IN SANITY AND IN INSANITY. 59 citizen of rugged character, dependability, and strength of purpose is said to possess a heart of oak. Spring foliage represents inexperience (verdancy) ; brown and yellow, decay (the sear and yellow leaf). Stone is a symbol of hardness, and there are cor- respondingly hearts of flint. The ascent of a river and the exploration of a cave are begun from the mouth. The volcano vomits forth its lava stream, and the earth clothes itself in a green garment. There is the family tree derived from the symbol of trunk (pro- genitor), offshoots and branches (near and remote relatives). One goes to the root of a subject, even as the tap root penetrates deeply the soil. The posi- tion "up a tree" is embarrassing and difficult, as many a cat has discovered. The hills are a symbol of hopefulness and suste- nance. "I will lift up mine eyes unto the hills from whence cometh my help." The sea is represented by Schiller as laughing and inviting to the bath, and in its tempestuous moments it distinctly says to a not unduly imaginative friend of mine "I am coming to get you." Every region has its twin lakes ; there are in the Yel- lowstone Park Teton Mountains; America has its backbone; Michigan has its thumb; Italy, its toe and heel. There are the lap and bosom and womb of nature as well as the bowels of the earth, the nose of the ship, the face of the cliff, the brow of the hill. In Scripture imagery the deserts shall rejoice and the wind is endowed with volition. It "bloweth where it listeth." There is resurrection of truth crushed to earth. The automobile engine shows distress and "charity suffereth long and is kind," the attribute in the latter instance standing for the individual whose 60 SYMBOLISM IN SANITY AND IN INSANITY. breasts overflowing with the milk of human kindness is its highly endowed possessor. Nature lovers and probably not a few fakers harken to the call of the wilds in vacation time, provided the pinch of poverty does not detain them at home. One may experience the touch of nature or that of defilement, be touched by suffering, and touched in his exchequer through a wild-cat enterprise. Wealth may come to all except the physician by leaps and bounds. An onion has its skin, likewise the banana, and peeling either is signifi- cant to the sensualist. The candidate for a degree gives head and body to his thesis and the pugilist puts a head on some portion of his antagonist's body. There are the head of the church, the head of the pro- cession, the head of the lake, and a long, heavy train drawn by two locomotives is designated a double- header. There are the neck of land, the eye single to that which is good, the jaws of an instrument, the chest of tools, the lip of scorn, the finger of destiny. Little pitchers have ears, the sea arms, the waves a voice, the mountain a foot, a comet head and tail, the potato eyes. Plumbers use male and female fittings, nipples and elbows in their vocation. Human sym- pathy has breadth, affection depth, folly height. A character is spoken of as well rounded; sarcasm, as pointed. Duty calls, happiness rains, the stone has a face, and the elements on occasions display anger. Dispositions are sweet and sour; certain forms of jest- ing leave a bitter taste. One scents trouble. One does not require a sleeping car to negotiate the distance be- tween Paradise Valley and Devil's Lake, and need not ordinarily waste trolley fare in a trip from poverty flats to nob hill. It would not be necessary to delve SYMBOLISM IN SANITY AND IN INSANITY. 61 deeply for the origin of the expression "they do noj; hit it off together" used in the politest conversation as concerning two antipathetic individuals. Certain char- acters are designated as flabby and certain heads as soft. The sun rules by day, the moon and stars by night, and the moon governs the tides. The May pole is said to be a survival of phallic adoration. One is understood to be a good swords- man if his weapon of offense is adjusted to more than one sheath, and different fur-bearing animals sym- bolize sexual parts. The older members of the pro- fession will recall the imaginative expression "nest hiding" as mentioned in a notorious ecclesiastical trial of many years ago. A sound and meritorious bill may be emasculated in committee and the virility lost from a burning question by ineffective discussion. We are interested in living issues and attend obsequies of the dead past. There is the rock of faith to which the sandy or gritty (courageous) soul may cling until his sands run out, his position preventing even the small legacy of a "footprint in the sands of time." One discountenances a wrong by making a wry face. There is an injunction to purge your conscience of dead works. One in contempt of court may be purged of this contempt if satisfactory explanation is forth- coming. In death the silver cord (spinal) is loosed, the golden bowl (skull and contents) is broken, the pitcher (heart) is broken at the fountain, and the wheel (kidneys) at the cistern. There are native and foreign tongues, the tongue of land, and tongues of fire that lap up the inflammable. A likeness may be speaking. There are the flood of criticism, the broivn study, the breath of suspicion. 62 SYMBOLISM IN SANITY AND IN INSANITY. A certain white fur is the symbol of purity, because of the dainty habits of the ermine; the stork symbol- izes piety and thankfulness; acacia, cypress, and cedar durability (immortality), for their qualities of resist- ance to the ravages of decay and insects. The palm suggests triumph, because of its elasticity and power of resistance. Tears are pearls ("Perlen bedeuten Thranen"). Events never happened thirty-nine or forty-five years ago, but to the reminiscent invariably occurred forty years ago. It would be interesting to discover how far the assignment of this number was deter- mined by Scriptural incidents, the forty days and nights' deluge, the forty years in the wilderness, the fast of forty days. Was the expression "three times and out" determined by the crow of the cock accom- panying Peter's denial of Christ, and is the notorious partiality for the use of the number three occasioned by the period of Christ's interment before the resurrec- tion, and by the Trinity concept? One can hardly escape looking for the third accident or misadventure in the presence of two preceding. The tragic incidents succeeding the last supper prevent the meticulous housewife from seating thirteen at table. One "touches wood" to avert evil because with the early Christians "the wood" signified the cross of the Savior. To that portion of the anatomy upon which the body rests in sitting has been vulgarly given the name of a domestic animal, a burden bearer. The subtle asso- ciation connected with this word was the cause of much trepidation on the part of a minister of my ac- quaintance. He felt himself constantly in danger in SYMBOLISM IN SANITY AND IN INSANITY. 63 reading the tenth commandment of conveying to his auditors the injunction not to covet his neighbor's "Ax nor his oss." Once, indeed, the mistake was made, as under the bewildering conditions was inevitable. Another friend avoided, where possible, pronouncing the name of a certain outdoor game because of an im- polite substitution for the true name, implanted in his boyish mind many years before. The plant and animal kingdoms furnish numerous examples of symbolism. There is a Trinity (three organs) represented by the clematis. The poppy signifies the immature product of conception. Ref- erence to the menstrual flow is made by the use of the word flowers. Apples constitute a well-known symbol for the breasts, which are also known as bubbles or brothers. Owing to the fact that they furnish the germinal principle, the name for a fruit of the tree is applied vulgarly to the contents of the scrotal sac. Because of the shape and covering of certain roots arid fruits their names have been transferred to the principal organ of generation in the male. Eggs suggest the fundamental facts of li f e-continuance. Colors are lively and gay or somber. White is emblematic of chastity, green of verdancy or jealousy (the green-eyed monster), red of brightness and optimism, and gray of the reverse of these. Red also stands for anarchy. Yellow has come to be identified with mental debility (jaundice, cachexia, and that which is undesirable, the yellow journal). Brown symbolizes certain bodily parts and functions. There is Scriptural authority for "though thy sins be as scarlet." Blue is the tint of emotional depression; 64 SYMBOLISM IN SANITY AND IN INSANITY. cardinal and purple point to authority, ecclesiastical or regal. The Klang association, that of words of the same sound as pronounced, but of different signification, is the occasion of much embarrassment and inconve- nience to the susceptible. Take, for example, through the word "bear," the suggestion of a burden physical or mental, parturition, a wild animal, and, because of sound association through "bare," that of nudity. The word "ball" suggests the national game, the tango, a bearing in a wheel, its unrelated "bawl," the cry of an infant, and milk of magnesia. The word "grip" sug- gests a fraternal order, friendship, poverty, disease, and death. The right and left associations are, as everybody knows, among the most common, the left implying the negative, neglected, and insincere; the right, the positive, straightforward, and dependable. Such associations as those above mentioned are uni- versal. They insistently obtrude themselves into thinking like Banquo's ghost at the table of Macbeth. In health they are for the most part ignored and are the source of no particular discomfort. In mental dis- ease, on the contrary, they become the bases for dis- tressing word obsession. Dementia praecox, the paranoid, hysteric, and hys- teroidal states furnish the best examples of such ob- session. A suppressed sexual experience in early life, the complex of the Freud school, not rarely supplies the groundwork for painful, provoking, and persistent mental hammering and determines morbid conduct in pronounced degree. Indecisions, negativism, and mutism may owe their origin to a subtle something below the plane of conscious acting, and irritability SYMBOLISM IN SANITY AND IN INSANITY. 65 and verbal castigation of other people are in certain cases interpretable as self -censure for previous trans- gressions. Emotions inspired by the imperfect revela- tion to the patient of a mental cesspool give rise to religious doubts and misgivings and to the delusion of loss of soul. "Salt" with which one was obsessed re- ferred to this article used on the finger-tips for the purpose of titillation of the sexual organs. Another once spoke irritably of an instrument of porcelain used on her mother. The mother proved to be herself and the instrument of porcelain her own finger in- serted into the vagina. The symbol of the serpent is as old as mythology. A black snake mentioned by one referred to the person of a brunette male acquaintance. The delusion of fatherhood in an unmarried virgin had its origin in playful contact with another little girl in childhood. Poppies and the fig-leaf are mentioned by those whose thoughts frequently revert to the sexual apparatus. Green pastures symbolize to one that which is fed upon as well as that which produces. The "corner of Pine Street and Broadway" was translated as indicating first sexual pining, second the "broad way" which leadeth to destruction, or in her language "where any old thing might happen." The color green affronted one patient because of the intimation of lack of worldly wisdom. A command to lift the curtain meant to uncover the figure. "Woman" suggested woo men. One was obsessed by the colloquial term for breasts. It came to her over and over and evidently originated from the self-scrutiny of vanity or from the less-comfortable emotion of chagrin because of ana- tomical imperfections. The word "banana" was by one divided into Anna and Nana and the false implica- 5 66 SYMBOLISM IN SANITY AND IN INSANITY. tion followed that Nantucket (took it). The obsession of the word "basket" was determined by the contents of a work basket amongst which was a darning ball, the handle of which had been used within the vagina. A skirt hanging on a banister conveyed an invitation to go up (stairs). Blackberries may be avoided because seedy ; spoons upon the table are looked upon as a re- flection. The word "Jackson" encountered in reading calls out the irritable assertion that there was never any Jack or any son. Reds and browns symbolize the pelvic organs and certain bodily functions; green, the apron of Adam and Eve. It is a safe color because of the experiences in the Garden of Eden. Prunes sug- gest prudery. (Prunes and Prisms.) Certain drawings and art productions of the insane display occult associations of symbolic significance. Question of a patient. Isn't that a beautiful head? Ans. Yes. Q. From what did you copy it? Ans. The temptation of St. Anthony. Q. What does the clover-like drawing signify? A. The Trinity. Q. Anything else? A. I don't know, trailing arbutus, hepatica. It has fuzz on the stem. Q. Of what is it all symbolic? A. Nothing. Oh, that dreadful sym- bolism. Q. What does the particular drawing sig- nify? A. An ellipse, a something to be desired. (At the same time making a tracing.) Q. In its entirety it is a sexual symbol, is it not? A. I don't know very likely perhaps it was they were there together. (St. Anthony and the tempt r ess?) One wrote : "The feathery clematis is to me as the fluffy winter girl. To study you what a trinity each branch, each terminus, holds to me, plumed seed, a thought, an emblem of Free Masonry." The fluffiness SYMBOLISM IN SANITY AND IN INSANITY. 67 referred to a peculiarity of the clematis blossom; trinity, to the three-branch division of the blossom; feathery and plumed, to the chapeau of a Knight Templar in whom she had been interested. Maeterlinck's Jocelyn suggested to one The Copley Society, Copley in turn calling up "Home, family." It goes way back to Genesis: "Be fruitful and multiply." The obsession "pig, pig," was determined in the case of one by the recollection of an erotic relation between herself and a summer boarder of the opposite sex. They had been sufficiently intimate for him to permit himself to name her breasts and he had placed his hand on different parts of her body. Once he ap- peared before a company carrying a young pig. With the subsidence of the sexual interest this symbolized in her mind that which is dirty and fleshly. A patient was insulted because mention was made to her of the theater opening night and because a man friend had invited her to visit the monkey house at the zoo. The color red was extremely objectionable to one patient because of some occult association. This could never be definitely brought to light, but it is con- jectured it has to do with the menstrual flow, and to childish impressions thereto related. Another had a prejudice against trees, because they suggested the woods from which she felt she must emerge. The figure of an owl perched in the middle of an oval belt buckle symbolized to the artist "wisdom in eugenics" or scientific, intelligently directed, perhaps artificial impregnation. . It is not difficult to understand in the light of all this how morbid thinking is promoted through fleeting im- 68 SYMBOLISM IN SANITY AND IN INSANITY. pressions obtained from without, through touch, taste, hearing, sight, and smell. What is read is miscon- strued and given personal application. Attitudes are misunderstood; the meaning of words is perverted, and there is distortion of the most commonplace ex- periences of everyday life. If it is possible to uncover the complex from which a word obsession originates it is often extremely help- ful to the patient to do this. Brought to light, its im- portance may be minimized, its in most cases utter in- significance emphasized. Many are greatly relieved to know that they are not alone in harboring symbols of an erotic and questionable character, and that in under- lying motives, reactions to environment and response to the incidents of earlier years, there is much that all the world has in common and recalls with chagrin ; but that to attempt to suppress recollection is futile, and to indulge in self-castigation utterly inexpedient. PART III. INSANITY. INSANITY is defined as "a prolonged departure from the individual's normal standard of thinking, feeling, and acting"* It is a prolonged departure, because there are many conditions in which there are temporary departures from the normal standard of thinking, feeling, and act- ing which are not called insanity. Thus, in intoxica- tion one neither thinks, feels, nor acts as when sober, but this is not accounted an insane condition, and the subject is fully responsible in the eyes of the law for his conduct. It is true of shock, a blow on the head, fright, an epileptic convulsion, fainting (from loss of blood or heart-failure), and apoplexy, that there may be temporary loss of consciousness and the mind does not act naturally ; but the person thus suffering is not regarded insane. Insanity may develop in consequence of injury, in consequence of the loss of blood, and in consequence of apoplexy or epilepsy; but the insane condition is here secondary and due to accompany- 1 All definitions of insanity must be more or less arbitrary, inadequate, and open to objection, but this, the simplest one with which I am familiar, designates tolerably well those con- ditions of mental aberration with which alienists have chiefly to deal, and will for working purposes ordinarily be found sufficient. (69) 70 INSANITY. ing change in nutrition of the brain or damage to its, structure. 1 The definition speaks of the individual's normal standard. This means that every case is a law unto itself : that there is no fixed standard of thinking, feel- ing, and acting. It cannot be said, for example, because one does not act under certain conditions as his neigh- bor acts, because he does not show the same amount of feeling that his neighbor manifests, or because he does not think in the same lines that his neighbor thinks, that he is insane and the other sane. In giving an opinion as to whether insanity exists, it is necessary to compare the person's present with his former habits of thinking, feeling, and acting. The "departure" may display itself in complete change of characteristics, tastes, and tendencies: in simple perversions of the feelings and judgments; or in an exaggeration of natural traits of character. Causes of Insanity. These are as numerous as the causes of disease in general. They may be classified, for convenience, ap- proximately as follows : Direct physical causes, 36 per cent. Indirect physical and emotional causes, 8 per cent. Vicious habits, 25 per cent. Constitutional and evolutional causes, 28 per cent. 1. Direct Physical Causes. These are such as affect mental operations through direct action upon the brain : a blow on the head; injury; hemorrhage; disease of 1 The word "insanity" means literally "unsoundness," but it is the medical, not the literal, meaning which is here given. INSANITY. 71 any kind, as cancer, consumption, Bright's disease; childbearing and its attendant perils; prolonged nurs- ing, etc. In each of these there is a direct action upon the brain, either from violence, through increase or diminution of its blood-supply, through deleterious substances carried in the blood, or through altered nervous sensations going from the part affected to the brain. 2. Indirect Physical and Emotional Causes. Under this head are grouped: fright; shock (not shock from surgical operation or bodily injury, but from sudden terrific strain upon the emotions); grief; care and anxiety; business failure; trouble of various kinds; domestic infelicity; disappointed affections; the feign- ing of insanity; companionship with those who are morbid; imitation. Causes such as these affect the brain indirectly through the physical system. For example, the man who has failed in business, loses sleep ; he does not take the proper amount of exercise, perhaps through fear of meeting acquaintances and having his troubles brought vividly before his mind; his appetite is impaired he takes food indifferently or refuses it altogether. He has actual distaste for food this because his changed habits of life have brought about disorder with the emunctories of the system the bowels, kidneys, skin, and lungs. What food he takes is imperfectly digested and badly assimilated. The blood-supply to the brain is insufficient and im- poverished in quality. Sleep is troubled by painful dreams, it does not rest him, and the process of repair which constantly goes on in the brain during sleep in the normal state is not carried on naturally during the period of emotional strain. Eventually, through all 72 INSANITY. these causes, he loses his ability to think, to feel, to act naturally ; and there comes to be a prolonged departure from his normal standard in these respects, constitut- ing insanity. 3. Vicious Habits. Under this head are classed: intemperance; opium, chloral, and cocaine addiction; sexual excess; self-abuse; and all habits of life which directly undermine the physical constitution and thus affect the brain. 1 4. Constitutional and Evolutional Causes. Under this head come all causes of insanity which operate be- cause of some innate defect in constitution or develop- ment of the individual. Here hereditary tendency figures to a great extent. One inherits a susceptibility, so called, to mental disease from intemperate, vicious, insane, or delicate ancestors. His nervous constitution is unequal to the task of carrying him through certain inevitable crises in development. There is known hereditary tendency to mental diseases, either remote or immediate, in about 50 per cent, of all cases under treatment in large institutions. Probably if the facts were invariably discoverable, the percentage would be found vastly greater. Among the constitutional and evolutional causes are Pubescence. The pubescent period is that during which the boy or girl passes to manhood or woman- hood. At this period the organs of reproduction take on development and a change in characteristics and personality occurs. Certain desires, aspirations, and tendencies not before felt are then first experienced. 1 It will be observed that vicious habits are, after all, but direct causes; but for convenience and clearness they are separately considered. i INSANITY. 73 It is a critical time in the life of the individual, and unless he or she is well organized, mental overthrow is apt to occur. One of the forms of manic-depressive insanity (the recurrent) frequently develops at this stage of life. The age at which pubescence is estab- lished varies in different climates. For this climate it is approximately from 13 to 15 years. Adolescence. Possibly the individual may have passed safely the pubescent period, having inherited sufficient nervous strength to carry him beyond this first physiological crisis, but at the next developmental period (that of adolescence) he breaks down, without direct assignable cause, or from some cause which would be insufficient to produce insanity in one well constituted. The adolescent period comes at the age of 25 to 35. Again : The mile-stones Pubescence and Adolescence may be left behind in the march of development, and the person go on mentally well until the change of life, the so-known Climacteric Period. This change in the woman takes place at the age of about 45; in the man, between 50 and 60. It marks in both a sta- tionary plane. The period of development is past, and those organs which took on activity at the time of the pubescent epoch begin to cease active functionating. Involution, the opposite of evolution, begins at this time and in fifteen years or thereabouts in the woman of 60 and the man of 70 Senile changes (those due to old age) 1 make their appearance, and mental and bodily feebleness ensues. Frequently 1 Every person has his limitations and possibilities, and earlier senility may occur if one's nervous and mental energy has not been conserved and if the output has been excessive. 74 INSANITY. mental enfeeblement reaches such an extreme that insanity is said to exist. We have thus the four periods : Pubescence, mark- ing the advance from youth to manhood; Adolescence, that from manhood to maturity (these two periods are developmental or evolutional) ; Climacteric, the sta- tionary period ; and Senile, the dissolutional period, or period of decay. Causes of insanity may be conveniently grouped under one of the four heads above mentioned. In every case the natural constitution of the subject figures to a greater or less extent. It is true of -the direct and indirect physical causes, as well as of vicious habits, that a cause feeble in its intensity may produce a disturbance of balance in one not well organized, whereas one having a good nervous inheri- tance and strong mental equipment may be able to resist the cause and retain his integrity of mind. Forms of Insanity. There is no such thing, strictly speaking, as a dis- ease of the mind; but the expression is commonly employed, and is a convenient one for describing dis- turbances of those operations of the brain which in- volve consciousness. Mental disease is always asso- ciated with disturbance of function or structure of the brain. Among the pathological conditions are conges- tions, effusions, anaemia (lack of blood-supply), opaci- ties of the membranes, thinning of the gray matter, adhesions of the membranes to the cortex of the brain, and degeneration of brain matter. The names commonly employed in the classification INSANITY. 75 of mental disease chiefly stand for groups of symp- toms: Mania being a Greek word, meaning furor; Dementia being derived from two Latin words: de, without, and mens, the mind; Paranoia, from Greek words para, defective, and nous, understanding. One notable exception is in the name Melancholia, which comes from two Greek words meaning "black bile," it being supposed by the ancients that this affection was incident to disorder of the liver. The classification of insanity and the study of in- sane conditions have undergone modifications almost revolutionary in very recent years. The former divi- sion of insane conditions into States of Mental Elation, States of Mental Depression, and Structural Brain Disease with Prominent Mental Manifestations, is generally regarded as inadequate for clinical study. The so-called states of mental elation and states of mental depression are now considered under the head of manic-depressive insanity, the terms mania, hypo- mania, delirious mania, etc., being employed to indi- cate the symptoms in existence during the excited periods; "depressive states" and "apathetic states" being used to designate the condition in depressed periods heretofore described as melancholia, and the term melancholia limited in its application to mental depression occurring in the senile or presenile (in- volutional) period of life. Terminal dementia and dementia following acute forms heretofore designated as chronic dementia, dementia after mania, and de- mentia after melancholia are no longer admitted as entities in classification, those cases of insanity here- tofore studied under the latter heads being relegated to other groups. This reformation in classification 76 INSANITY. has been due to the recognition of a state underlying the morbid nervous processes of which so-called mania, melancholia and dementia are the expression, namely, the neuropathic organization. Under the old classification embarrassment was frequently en- countered in clinical study because of the mixed manifestations in the so-called acute forms of dis- ease, the maniacal patient being rarely consistently maniacal and showing an exalted state of the emo- tions, the depressed patient displaying from time to time fluctuations in the emotional states to an extent incompatible with trip grouping of symptoms under states of emotional depression. Further, the so- called recurrent mania (folie circulaire) presented the picture of alternating states of elation and depression with or without intervals of lucidity, the pendulum at one time swinging over to lowered emotional tone, then to the other extreme. These clinical facts led to the study of the manic-depressive insanities under the one head, and the essential unity of so-called mania and melancholia is now generally recognized. Simul- taneously with the disappearance of these forms of disease as clinical entities, there was brought forth a name under which is included certain conditions of psychical degeneration displaying by turns the symp- toms of mania and melancholia, of stupor and of dementia. Its existence is regarded as marking psychi- cal degeneration from the beginning. It is the so- called dementia praecox. The classification here employed is practically that adopted by the National Committee for Mental Hy- giene, variations therefrom being mainly those neces- sitated by the elementary character of the book. A INSANITY. 77 similar constraint prevents fuller consideration of the pathological groundwork of insane conditions. Infection Psychoses. 1 Under the infection psychoses are included the delir- ium of fever, the delirium directly due to infection, and the morbid mental states following fever. These conditions are attributable to the immediate or remote effects of the toxins or poisons of infectious diseases. The phenomena of FEVER DELIRIUM are familiar. Coincidently with the occurrence of fever there are developed flightiness of conduct, dream states, hallu- cinations, wandering speech, and increased sensitive- ness to touch, to sound, and to sight, depending upon the grade of fever and the nervous constitution of the individual. Certain children invariably display delirium in the progress of any febrile disorder. In- deed, in some, illness, however slight, is accompanied by head symptoms. The simple digestive derange- ments, the eruptive diseases, and the cutting of teeth are attended by temperature and delirium. The grade of delirium as a rule corresponds to the degree of temperature, to the activity of the poison which gives rise to the fever, to the rapidity of tissue change, to the extent to which the circulation is dis- turbed, and to the previous habits of the individual, particularly as to alcoholic indulgence. In the severe grades the movements of the patient are purposeless, there are complete incoherence and unconsciousness 1 Psychosis (plural, psychoses) signifies any form of mental derangement, more particularly where there is no discernible pathological condition in the brain to account for the de- partures from the normal. 78 INSANITY. .of surroundings. There may be obliteration of per- ception and consciousness, with apparent wakefulness and staring eyes, the so-called coma vigil. Inconti- nence of urine and lack of control of the bowels are present. The delirium may subside with -the fever and consciousness become clear, or the morbid impres- sions developed during delirium may continue after its subsidence. Delirium accompanying pneumonia has in my ex- perience led to the unwise removal of a patient from her home to a hospital for the insane. This disease occurring in an habitual drinker is prone to give rise to hallucinatory impressions colored largely as are those of pure alcoholic delirium. States of profound hebetude and torpor attend upon certain forms of influenza. There are emotional de- pression, dullness, and indisposition to exertion, and, after the subsidence of fever, enduring lassitude, per- haps going over into neurasthenia. In one instance, indeed, epilepsy owed its origin in a previously vigor- ous man to an attack of la grippe. The delirium of typhoid fever is not, as a rule, of an active character. Muttering, picking at the bed- clothes, tremulous movements, startings, and twitch- ings are present, but no pronounced muscular activity. Occasionally, however, intense hallucinatory or illu- sional impressions and the fear of injury impel the feeble patient to rise from bed, cause him to make determined resistance to his nurses, and lead to death from precipitation from the window or stairway. In INFECTION DELIRIUM, that is to say, that form directly due to the septic poison of the disease, there is no definite relation to temperature. There are delu- INSANITY. 79 sions of persecution, the emotions are depressed, and visual and auditory hallucinations occur. Confusion of ideas, and extreme restlessness and incoherence are present in some cases. Diefendorf (Kraepelin) says that in small-pox during the formation of pustules between the eruption and pus fever, there is a charac- teristic mental disturbance which seems due to infec- tion. The grade of delirium of typhoid fever varies according to the severity of the physical symptoms. That it is not the prolonged temperature alone that determines the delirious state, but actual damage done to the brain by the circulation in the blood of a poison- ous principle, is considered probable because of the frequent apparently causative relation of the typhoid to subsequent and often permanent mental impair- ment (dementia prsecox). Facial erysipelas is frequently accompanied by de- lirium. Rheumatism, endocarditis, and chorea, all re- lated diseases, may be attended with grave confusional and hallucinatory manifestations. Delirium occurs in hydrophobia and terminates in fatal collapse. In POST-FEBRILE conditions there are often inepti- tude, lethargy, incapacity for concentrating the atten- tion, delusions, and indifference. The germ of insanity may find itself in the delirium developed during the progress of fever, or the mental disturbance may come on after the subsidence of temperature. Patients be- come irritable and depressed, hallucinations are occa- sionally in evidence, and in some cases delusions of distrust and persecution appear. Dangerous impulses may be present. In the most severe cases, delusions of persecution are well marked. There is complete in- coherence, the speech is confused, suspiciousness is 80 INSANITY. present, and there are delusions of unseen agency and poison. Hystero-maniacal and manic-depressive states, at- tended with strong antipathies toward relatives and those in the immediate care of the patient, occasionally develop in consequence of some of the fevers, notably the rheumatic. Fevers may also be the starting point or determining cause of a subsequent dementia prsecox. The physical state is undermined by the rheumatic con- dition, and the cardiac and other evils attendant upo.i it. The young patient in consequence of the condition of invalidism is indulged and the will-power and self- control remain undeveloped. Patients grow impulsive, irritable, fretful, inconsiderate, and are subject to emo- tional storms. Under the head of Post-febrile Infections, a Psy- chosis, with simple neuritis (Korsakoff's), has been described, the characteristics of which are feeble memory, failure of attention, and a disposition to fabricate. The symptoms may be differentiated from those of paretic dementia by the absence of pupillary phenomena, disturbance of speech, and other motor indications of the latter disease. Treatment. The treatment of febrile delirium and infection delirium should be largely directed to the physical symptoms. Elimination by the skin, by the kidneys, and by the bowels should be favored. The high flushing of the bowels is especially valuable. The ice-cap to the head, cool sponging to reduce tempera- ture, and the use of remedies, strychnine, caffeine, and quinine, to support the heart's action, are valuable. In cases where it is impossible to induce the patient to take sufficient liquid nourishment by the mouth, re- INSANITY. 81 course should be had to rectal alimentation the giving of nutritive enemata, of water or of the normal salt solution, by the bowel. In all delirious conditions it is necessary that the patient be given watchful attention owing to the danger of self-injury. Mechanical re- straint, as with the rest sheet, is sometimes indis- pensable. The treatment of the post-febrile psychoses may in- volve rest in bed for a considerable period of time. Attention should be directed to building up the general health. Where neuritis is an element in the psychosis, treatment should be directed to that condition. Pa- tients with well-marked delusions of suspicion in re- spect to their environment will be more likely to improve under hospital conditions than at home. In cases where suspiciousness is so strong as to create de- lusions of poison, tube-feeding may be necessary. A tonic medicinal regimen is indicated. Exhaustion Psychoses. Under this head are grouped insanities due to ex- treme nervous reduction. They are of sudden onset and pursue a rapid course to recovery, or terminate in chronic states of nervous exhaustion. The exciting causes are childbirth, prolonged lactation, excessive mental strain and shock, intense care and anxiety, fractures, particularly where there is the complication of precedent alcoholic over-indulgence. COLLAPSE DELIRIUM. Collapse delirium develops rapidly after a condition of sleeplessness. There are confusion of thought, restlessness, and excitement. There are incoherency and delusions of persecution and unseen agency. Threatening voices are heard which 6 82 INSANITY. impel the patient to impulsive acts, to jump from bed, to run about the room, and perhaps to precipitate her- self from the window. A young woman, the mother of two children, both living, whose health was good until marriage, broke down five years thereafter. There were delusions of apprehension and various auditory hallucinations of a painful character. A certain degree of mental and considerable physical betterment fol- lowed the removal of degenerated ovaries. She had fears that she was to be killed, and that her family and property were in danger. She refused food, omitted to empty the bladder, feared poison. There was negativism. Once after a hard struggle vainly made to catheterize, she turned to the nurse and said: "Now you may pass the catheter." She did sudden acts of violence, but had periods of self-control during which she conversed pleasantly on the subject of music. After the visit of a consulting physician whom she had not before seen she expressed the delusion that he had hypnotized her. This case furnished an excellent example of stereotypy in expression. She repeated over and over identical sentences and was constantly influenced by vivid hallucinations of hear- ing that her property had been stolen. Improvement occurred, then relapse, followed by physical prostration, complete refusal of food, regurgitation of that given by the tube, and profound confusion. Later both mental and physical betterment ap- peared, but the leading mental symptoms, remaining in evidence, indicate that the original collapse delirium was the initial period of a dementia praecox. Another patient suffering from collapse delirium also displayed stereotypy, repeating over and over "Tom here's your wife." In this form of disease there may be eroticism, extreme untidiness, and ex- posure of person. Such patients resist attention. The duration of collapse delirium is usually short and the first mental illumination appears suddenly. Convales- cence, once established, may go on rapidly or slowly in proportion to the amount of reduction the physical INSANITY. 83 -forces have sustained. The prognosis is favorable if the patient can be safeguarded from injury due to im- pulsive acts. ACUTE CONFUSION AL INSANITY. This condition is of sudden origin following exhaustive illness. There may be periods of unconsciousness preceded and fol- lowed by insomnia. Delusions of fear are present. The patient believes himself persecuted by those of other religious sects, impugns motives, asserts that his property is to be destroyed. Intermittent delusions of an exalted character may also be present. The patient is restless and, although weak and more or less help- less, is apt to be up and about. He fancies that others are: trying to work some scheme to obtain money, has hallucinations of sight, mistakes figures in the carpet for animals. Other hallucinations of the special senses may be present. There is disturbance of the tempera- ture sense. One patient that I knew believed that snow was falling in his room. There are extreme mental confusion and a tendency to impulsive and violent acts. There are variations in the emotional sphere, pleasur- able concepts alternating with those of a depressing character. There are apt to be deranged secretion, foul breath, and slight elevation of temperature. Suicidal attempts in frenzied states are not rare. A woman of rather frail physique, a farmer's wife and extremely industrious, who in a married life of fifteen years had given birth to four children, became suddenly depressed one month after the last confinement. This took place hur- riedly and delivery was instrumental, but, as in previous instances, unattended by any untoward event or accident She took part as spectator in a revival meeting, but was not apparently much impressed and said she could make nothing out of it. Later, however, she began to talk of different faults, that she had not told the truth, that she had been dishonest 84 INSANITY. in not looking up the owner of fifteen cents found as many years before. She took food sparingly and the milk supply ceased. She was indifferent to the removal of her baby to the house of a neighbor. She grew resistive, declined to wash her hands, would not permit attention from others. There were brief attacks of excitement, during which she ran from her room. She thought the devil in pursuit and expressed disbelief in God; became impressed with the delusion that her surroundings were filthy, talked but little, and this in whining, plaintive tone. There was great mental retardation. She omitted to empty the bladder except on suggestion from her husband, feared robbery, was repetitious; asked again and again if this is her room, what that picture is, where her husband is, what it all means, but did not heed replies. She believed herself improperly bathed, that the toilet room was unfit to use, that food served was not such as furnished to others. She was terrified when taken from her room for any reason and startled by noises, as of a distant engine whistle. Treatment. In the treatment of the acute, exhaust- ive psychoses, elimination should be favored, the skin, bowels, and kidneys being kept active. Rest in bed is imperative and forced alimentation may be necessary. Owing to the extreme excitement in some cases, tube- feeding may be from time to time demanded. Cool sponging and the alcohol rub are valuable. The pro- longed bath of from fifteen to twenty minutes' duration in water at a temperature of about 100 is serviceable in some cases where there is no resistance to this form of treatment. During the bath cold cloths should be applied to the head. Rest in bed with the ice-cap to the head is of value in some cases. Medicines to sus- tain the heart's action, either hypodermically or by the mouth, are useful. In giving medicine hypodermi- cally, care should be taken that the patient's delusions are not intensified by this method of administration. Where hypnotics are necessary, veronal or sulfonal in INSANITY. 85 5- to 10- grain doses may be employed. If chloral is used, strychnine or quinine should be administered with it to obviate its depressing effects. In order to prevent further exhaustion and collapse and to permit the application of cold to the head,, the rest sheet may be required. If possible, however, restraint should be avoided. CHRONIC NERVOUS EXHAUSTION (NEURASTHENIA). This condition follows shock, excessive mental ap- plication, prolonged mental strain, great anxiety, and sexual excess. In connection with the above causes there may be the additional factor of indulgence in alcohol taken with the idea of temporary relief from depression. The individual is conscious of inability to carry on his work as before. There is headache, particularly at the vertex and occiput. Pain at the vertex is described as "pressure" ; that at the back of the neck and occiput as "drawing," and one feels an instinctive desire to sus- tain the head with the hands. A vise-like constriction of the head is sometimes complained of. One breaking down with neurasthenia neglects his business little by little. He procrastinates and shuns active effort, finds it difficult to maintain his former relations to society, and by degrees drops out of it. He suffers from pain in the back and legs, talks of sexual incapacity, is sexually weak, is constipated, and is fatigued by exer- tion. He finds himself in a clammy perspiration after the slightest expenditure of force, is hypochondriacal, is bent upon talking about his symptoms, and does this in season and out of season. He imagines the kidneys do not act properly, that the blood is stagnant, and that the functions of different organs are inhibited or lost. 86 INSANITY. Frequently there is complaint of great exhaustion after a movement of the bowels. There are local anaesthe- sias, or painful points at the distribution of the super- ficial nerves. Patients become extremely sensitive; they lie in bed, demand unremitting attention, cannot brook the slightest noise about the house, insist upon closely drawn curtains, and cover the eyes to exclude light. They complain of lack of appetite, restrict them- selves to the lightest possible diet, develop foolish fads in eating, and imagine they must place dependence upon so-called "health foods." They complain of digestive symptoms, particularly of pain in the stom- ach, and gaseous eructations. They suffer from in- somnia and demand medicine for the relief of this condition. The faculty of voluntary attention is im- paired. There is occasionally the unfounded fear of syphilitic infection. Unless carefully safeguarded they are apt to become confirmed drug takers. There is a disposition to key up with alcohol or narcotics, which disposition, yielded to, aggravates the depression for which the stimulant was taken. All symptoms are most distressing in the early morning hours. Patients develop contractures of the hysteric type and mus- cular atrophy from disuse of the extremities. One under my care several years ago had been bedridden or confined to an invalid chair for twenty-five years. Her knees were contractured and the muscles of the thighs and legs almost completely atrophied from disuse. She was supposed to be the victim of spinal disease and had become, in consequence of neuralgic pains, a morphine habitue. The task of lifting this patient from despondency and re-establishing self- INSANITY. 87 confidence was very great, but was accomplished in due time. In neurasthenia the tendon reflexes are invariably exaggerated. Diagnosis. Many cases of paretic dementia of the apathetic or depressed type have been early diag- nosticated as neurasthenia. Marked impairment or absence of memory with pupillary abnormalities (con- tracted pupils, unequal pupils, or pupils of the Argyll- Robertson type) constitute practically conclusive evi- dence of the former condition. The Wassermann reaction- and spinal fluid examination discussed under the head of Paretic Dementia may be useful here for diagnostic purposes. An objection to this and to any surgical procedure lies in the danger of adding one more item to the patient's repertoire of disabilities. Treatment. The implication of the sympathetic nervous system in neurasthenic states is so pronounced in the symptomatology that to mention the one with- out immediate mental association with the physiology of the other is impossible. The vascular phenomena contraction-dilatation, the fluctuations of pallor and flushing, the delayed digestion, the rectal pain, the dilatation of the intestines and diminished peristalsis, the epigastric discomfort, the sudden perspiring all point to an extremely mobile state of this particular division of the nervous system. In its treatment ergot and small doses of atropine are indicated. Change of environment is of the utmost value and the hospital or sanitarium regime ideally adapted. Rapid change of scene, as travel, is not often pro- ductive of good. A patient going about from place to place, consults one physician and another, and is con- fused and made more self-centered by conflicting 88 INSANITY. opinions and differing medical prescriptions. The de- termination of the question of location should be made by others, and the carrying out of a wise plan of treat- ment for a number of months should be enjoined and insisted upon. Medicines to build up the general health and directed to disease of the stomach and intestines should be employed. The bowels should be kept regular by the use of aperients and the colon flushing. Diastasic essence of pancreas is a useful remedy for the frequently attendant intestinal indigestion. Medi- cine directed to the excess or diminution of hydro- chloric acid in the stomach, the necessity for which may be determined by an analysis of the stomach con- tents, may be employed. Electric massage, mechanical vibration of the muscles, and the static breeze are of service, the latter particularly for its suggestive and soothing effect. Hydrotherapy, particularly the Rus- sian bath and salt rub, followed by the cold spray to the spine and vigorous friction, are. particularly valuable. For the frequently attendant insomnia, a hot drink should be given at bedtime. If after a fair trial that proves insufficient, recourse may be had to veronal, sulfonal, or trional in small dose. The habit of de- pendence upon hypnotics is rapidly developed, how- ever, and the danger of it should be conscientiously borne in mind. After all, as a matter of fact, depress- ing medicines are distinctly contraindicated in such cases and are detrimental if much employed. Such patients are susceptible to suggestion, and a confident manner of administration goes far to increase the effi- cacy of remedies. INSANITY. 89 A patient once declared that the medicine called "placebo" helped her the most of any. Given with as- surance it will often be found useful in the sleepless- ness of neurasthenia. Intoxication Psychoses. These may develop from any poisonous substance taken into the body, prominent among which are alco- hol, opium and its preparations, cocaine, hemp, the ptomaines, and preparations of lead. LEAD POISONING produces a train of symptoms like those of organic brain disease. There are the charac- teristic paralyses of lead with possible colic; there are tremors, pains in the limbs, incoherence of speech, con- fusional states, sometimes delusions of fear, and occa- sionally epileptiform convulsions. Inquiry into the habits of life and the occupation of the patient usually suffices to differentiate this condition from organic de- mentia. The treatment should be directed to the elim- ination of the poison of the presence of which the nervous symptoms are an expression. ALCOHOLIC INTOXICATION. The phenomena of acute alcoholic intoxication are so well known as to require no extended notice. However, given a condi- tion of habitual inebriety and the erraticism incident thereto, it may be puzzling at times to decide at what period disturbance of thinking, feeling, and acting has reached the morbid degree, where responsibility leaves off and unaccountability for conduct begins. Varying with the natural disposition, there may be in simple intoxication exaltation or depression of emotional tone, belligerency, jealousy, periods of frenzy, stupor, de- 90 INSANITY. pending upon the amount of intoxicants taken into the system. DELIRIUM TREMENS. Acute alcoholic delirium, or delirium tremens, is of sudden onset, though there is frequently an antecedent period of gastric derangement with reduction in emotional tone, and impaired nutri- tion, due to the toxic effects of alcohol. The delirious condition arises in some cases during a prolonged drinking bout, in others after withdrawal of the habit- ual stimulant. Occasionally it develops as the imme- diate result of an injury. The susceptibility to delirium following fracture in subjects addicted to prolonged alcoholic indulgence is a matter of frequent observa- tion. Following the period of insomnia, of derange- ment of the stomach and alimentary canal, loss of appetite, and restlessness, a condition of mental excite- ment appears. There are increased sensitiveness and irritability, fretfulness, and impatience. Rapidly a condition of confusion supervenes and this goes on to delirium, more or less grave and pronounced, depend- ing upon the amount of intoxicant consumed and the susceptibility of the patient to its influence. Hallu- cinations of sight and hearing take place. Patients hear threatening noises and misconstrue ordinary con- versation and current sounds. They are suspicious. They see rats, vermin, and creeping and crawling things, dogs, cats, horses, and things going 'round and 'round. They distort figures in the carpet and wall paper, pick at the bedding, and are by turns incoherent, dazed, frenzied, and completely disoriented. They are impulsive and violent, and are apt to exhaust their strength to the border of collapse by struggling with those about them. From time to time during the INSANITY. 91 progress erf delirium there is a half -conscious apprecia- tion of the surroundings and the absurdity of morbid concepts, and the patient may be momentarily diverted, only to become lost again in vagaries and fantastic thoughts. Elevation of temperature and accelerated pulse are commonly noticed. During frenzy, particu- larly if manual restraint has been necessary and strug- gling with the patient has been entailed, there are pallor of the surface, cold sweat, and indications of impending collapse. Refusal of food takes place be- cause of loss of appetite and delusions of poison. Pa- tients are sleepless. Treatment. Patients should, if possible, have hos- pital or sanitarium care where special arrangements are made to prevent self-injury, where necessary re- straint may be employed and unnecessary coercion omitted. The room should be dark and quiet and noise minimized. There should be attention to elimination by the use of calomel and salines. Emptying of the lower bowel by enemata and of the colon by the high flushing is of service. Patients should be induced to take as much liquid as possible to favor elimination by the kidneys and skin. Where liquids are not taken readily by the mouth they may be introduced at fre- quent intervals by the rectum. The patient should be kept perfectly quiet. The presence of a level-headed nurse is necessary. Talking to the patient, except oc- casionally to say a soothing or quieting word, should be omitted. The calm manner and assuring tone of voice may be of great service in suggesting to the patient the unreality of morbid impressions, but much conversation on any subject is to be deprecated. Tepid or cool sponging at frequent intervals is of service. 92 INSANITY. The use of the ice-cap to the head and to the* precordial region in case of great rapidity of the heart's action is of much value. In diet, malted milk, digestible cocoa, coffee, eggnog without liquor, blanc-mange, floating island, beef peptonoids, soups, and broths may be used. Rectal alimentation is necessary in some cases where there is persistent refusal of food, and tube-feeding through the nose may be demanded. Medicinally, strychnine is the remedy of greatest value. From % to YSQ grain of strychnine may be given hypodermically once in four or six hours according to the condition of the heart and the general symptoms. Tincture of capsicum is valuable as a regular prescription, and may be given in doses of 10 to 15 drops three or four times a day. Alcohol should be immediately withdrawn. Other remedies besides those alluded to, as kola, coca, quinine, the aromatic spirit of ammonia, may be given throughout waking hours and furnish an entirely satis- factory substitute for alcohol. The patient should be allowed as much latitude as possible consistent with the preservation of strength. In the intervals of cold applications to the head he may, to rest himself, be per- mitted to walk about the room. When heart failure is threatened, however, confinement to bed should be enjoined and mechanical restraint used if necessary to insure this. Of sleep-producing remedies, the best in these conditions, in my judgment, is chloral. It is rarely necessary to give more than two doses of the drug, 20 grains at each dose, three hours apart. It may be given in connection with the valerianate of am- monia, with quinine, or with strychnine, and the addi- tion of one of the latter remedies where cardiac ex- haustion threatens is desirable. In private practice in INSANITY. 93 the treatment of these cases, chloral is a much-used and often-abused drug. Under home surroundings, the necessity for quieting the patient at any hazard leads to large and frequent doses of chloral combined with bromide of potassium. A state of confusion is induced ; there is serious reduction of the vital forces ; elimination is checked and toxins are retained. Other hypnotics, as veronal, sulfonal, and trional, may be used as necessary, and will be frequently found valuable. It may be expedient to give small doses of bromide of potassium, 10 to-15 grains, at intervals of four or five hours, where there is great nervous excite- ment, but this should be omitted otherwise. I am op- posed to the use of morphine and codeine in these cases, although in some instances they may be required to quiet extreme nervous agitation. Paraldehyde is In many cases invaluable in the insomnia due to with- drawal of alcoholic stimulants. One patient whose whims were most difficult to meet spoke of the com- fortable "glow" after its ingestion. It is, in fact, so very acceptable that the danger of establishing depend- ence upon it must be borne in mind. It may be pre- scribed in doses of 1 to 2 drams and, as a rule, one dose will suffice. To disguise its pungent taste the addition of gum acacia, oil of wintergreen, and syrup of wild cherry, after the formula of Shoemaker, is useful. DIPSOMANIA. In certain cases where there is strong hereditary instability, the disposition to drink to excess comes in waves or storms. There may be months of total abstinence or temperance, then of a sudden the unfortunate individual is engulfed in the whirlpool of indulgence. He leaves his business, however pressing 94 INSANITY. and important it may be, goes to an unfrequented part of his city or to a distant point, and for days on weeks indulges the appetite to drink to the limit. Clearing up comes as suddenly. A tapering off process begins. There are needed a few doses of the bromides, two or three seances at the Turkish bath, and the wreck of the week before, now rehabilitated, resumes his place at the desk or in the counting-room, clothed and in his right mind. The disease manifesting itself thus is called dipsomania, a term which is properly applied to this, and only this, form .of alcoholic inebriety. CHRONIC ALCOHOLISM is attended by progressive mental deterioration and by physical symptoms denot- ing change in the central nervous system. The patho- logical changes are those due to arteriosclerosis, menin- gitis, and cerebral atrophy. Progressive impairment of memory and attention occurs ; there is failure of judg- ment and inability to carry on business in a satisfactory manner. The conversation is mixed and there is de- terioration in personal habits. The moral ideals are lowered, there is an ignoring of conventions; from being careful in manner and speech one becomes coarse and unrefined, unreasoning prejudices are developed, and patients are at sixes and sevens with relatives. There are inconsistent complainings; patients believe themselves deprived of opportunities and attribute to others the lack of success which the vicious indulgence has brought about. Natural affection disappears. ALCOHOLIC DELUSIONAL INSANITY. A step further in the degenerative process and there are well-marked delusions. With patients who are married the idea of infidelity on the part of the wife or husband is fre- quently present. The basis for this is often sexual INSANITY. 95 repugnance, on the one side, or inadequacy on the other. There is extreme irritability. Persecutory de- lusions are present. Hallucinations of hearing are fre- quent; the patient hears voices threatening him, ac- cusing him of crime, and his wife of infidelity. At this stage there is frequently a strong prejudice against alcohol in any form. I have often known patients in debilitated condition for whom an eggnog or light alcoholic stimulant was prepared, to refuse it abso- lutely. There seems to develop a distaste for the habitual stimulant. There may or may not be tremor and indications of muscular weakness. ALCOHOLIC PSEUDO- PARESIS. In certain cases of chronic alcoholism there develop symptoms simulating those of organic brain disease. There are present fine muscular tremor, ataxia, muscular atrophy, uncertainty in gait, defective speech, frequent headaches, vertigo, exaggeration of tendon reflexes, loss of memory, and epileptiform attacks. The gait is often peculiar; the patient walks with rapidity, but showing muscular inco-ordination, comes to sudden stops, then rushes on as before. He is unable to give himself satisfactory attention in dressing, the personal habits become un- tidy, there is fibrillary twitching of the tongue: the memory is feeble, the patient cannot find his room, he is unable to write, and if he undertakes this the result is a sorry scrawl. There is at times a tendency to extreme somnolence. The reflexes are often exag- gerated to that extent that muscular contraction takes place throughout the entire extremity by tapping the patellar tendon. Along with the extreme muddling and mental confusion, there are hallucinations of hear- ing. One patient heard girls making merry outside 96 INSANITY. his window, another the noise of a sewing machine. There may be impressions of water running through the ceiling. Patients imagine their lives are threatened and hear pistol shots. The recollection of incidents during active excitement is much disturbed, and un- founded prejudices arise against those having the care of the patient. Alcoholic pseudo-paresis may be mistaken for true paretic dementia. In a marked case which came under my observation some years ago there were extravagant delusions, the pin-hole pupil, indistinctness in articu- lation, visceral delusions, and marked ataxia in gait and speech. Regis says that inequality of pupils is scarcely ever lacking in alcoholic pseudo-paresis. The pupillary aperture may be misshapen, the pupil dull and cloudy, and visual acuteness less. The ataxic symptoms rapidly clear up after active elimination, rest, and quiet. Bevan Lewis speaks of the motor dis- turbance in alcoholic pseudo-paresis as motor impo- tence, not inco-ordination. The earliest indication is a fine muscular tremor, implicating first the fingers and hand, gradually spreading to the arm, next involv- ing the tongue, lips, and articulatory muscles. generally, and lastly extending to the foot and leg. The occur- rence of epileptiform seizures similar to those appear- ing in the progress of paretic dementia, complicates the diagnosis in a small number of cases. The seizures are in no respect different from those encountered in true paretic dementia. Occurring in connection with slug- gish and unequal pupils, exaggerated tendon reflexes, ataxia, incoherent speech, untidiness in habits, halluci- nations of hearing, extreme mental confusion, dis- orderliness of conduct, general obtunding of the mental INSANITY. 97 faculties, and loss of control over the sphincters, as was the case in a patient who recovered, a correct diag- nosis in the early stages of the malady may be impos- sible. In one case displaying this train of symptoms, the mental disturbance disappeared entirely during the first month, and within three months the reflexes, theretofore greatly exaggerated, were normal, there was no evidence of ataxia, there were equal pupils and distinct articulation. The handwriting was good. Ex- perience in this and other cases would seem to empha- size the importance of careful inquiry into etiology and sufficient observation of the case after withdrawal of the stimulant and complete rest to make sure of the diagnosis. Cases of this kind may progress with but slight involvement , of pulse and temperature. A. W. Kurd writes of differential diagnosis as fol- lows: "The motor symptoms in paresis are generally more localized than in alcoholic dementia the seats of election at first being more especially in the muscles of locomotion and articulation, while in alcoholism the tremor and trembling are more generally distributed ; with the general tremor, real muscular weakness is more marked than in paresis. In the early period the trembling of the hands is more conspicuous than in paresis, while the inco-ordination is apt to be less. The interference with the muscles of articulation, while possibly present in both, is more pronounced in paresis, and the elision of syllables, the omission of syllables or letters, quite characteristic, but difficult to describe, is more pronounced while in alcoholism the difficulty of articulation appears to be a more constant general tremor of the muscles, without the lapses and spas- modic pauses." 7 98 INSANITY. A positive Wassermann reaction and the findings from spinal fluid examination may serve to practically clear the diagnosis. (See page 133.) Treatment, Withdrawal of alcohol and a tonic non- alcoholic medicinal regimen are necessary. Strychnine in small doses, three times a day, is a valuable tonic. When the rest is disturbed it may be promoted by taking some warm drink at bedtime. Especial atten- tion should be paid to elimination. The patient should take large quantities of water. A nourishing diet should be prescribed. Hydrotherapy is of great im- portance. The steam bath, and subsequent salt glow and shower, are of value. Effort should be made to build up the general health by out-of-door exercise and indoor calisthenics. Games and other diversions are of much service. ALCOHOLIC PARANOIA. The delusional state in cer- tain cases of alcoholic insanity may simulate paranoia. Women suffering from this disease believe themselves to be queens and persons of superior birth. There are delusions of suspicion and of conspiracy. The conver- sation is frequently indecent ; the wife believes herself persecuted by her husband, who plans to have her killed in a runaway accident to obtain imaginary life insurance. The patient may feel much responsibility resting upon her and be impelled, as in a case of my own, to make bread and butter by opening and closing the window. There are extravagant fancies. Useless purchases are made ; the dress is fantastic. One may write poetry and imagine herself an accomplished musician or authoress; that her treatment away from home is a sacrifice because of some understanding with another government. There are hallucinations of INSANITY. 99 hearing, messages are conveyed through speaking- tubes, and communications sent out by turning the handles of water coolers. A symbolical significance is discovered in a picture, in the disposition of some article of furniture, or in table arrangements. One patient who murdered his wife by striking her on the head with an axe committed the act because he read in lettuce, radishes, and onions served at one time on the table, "Let us re-disunion." Treatment. The general considerations pertaining to the treatment of chronic insanities apply to the care of these conditions. ALCOHOLIC EPILEPSY. Occasionally grave epilepti- form attacks occur without the accompanying mani- festations of ataxia mentioned under the head of Alcoholic Pseudo-paresis. Indeed, a sudden nervous explosion of this character may be the first warning received by the patient that his or her drinking is ex- ceeding the bounds of moderation. A strikingly interesting incident of this kind was observed in the case of a woman patient of mature years. Seizures of an epileptoid character occurred after intervals of a week or fortnight. There was profound unconscious- ness and injury was done to the head in a fall accom- panying one of the attacks. This patient showed no sign of deterioration in intellect or in the motor sphere and made an excellent recovery consecutive upon the withdrawal of alcoholic stimulants and upbuilding the general health. MORPHINE AND OPIUM ADDICTION. Causes: I am by no means prepared to admit, after the treatment of morphine and opium addiction for many years, that the majority or more than a large percentage of cases are 100 INSANITY. due to the injudicious prescription of the physician. While some develop because of the continuance of a physician's prescription (often without his knowledge) for an undue length of time, many originate from pure self-indulgence. It is true in all probability that mor- phine is used too liberally in the treatment of neu- ralgic conditions. It is too frequently the first re- sort and one dose is followed by another and another until the patient is under the tyranny of the habit. Unfortunately, those to whom narcotic drugs are easily accessible, as physicians and pharmacists, who know perfectly well the dangers which menace one in the employment of drugs habitually, fall into the way of taking opium or some of its extractives in the place of some other form of stimulant. A physician after an arduous day's work finds it convenient to secure rest and repose by taking a small hypodermic injection. He has a feeling of indifference to its danger, is aware of the insidiousness of the drug and the horrors attendant upon its habitual use, but takes it with that confidence in employing the tools of his profession which familiar- ity breeds. Uncomplicated cases of morphine addiction are rarer than formerly. In not a few instances cocaine is re- sorted to at the time the depressing effect of the first taken narcotic falls upon the patient. This complica- tion adds to the difficulties in the way of treatment. On the contrary, one of the least difficult patients it has been my experience to treat had regularly taken stimulating drugs with the morphine. He had had every two hours or thereabouts 3 grains of acetanilid, 2 grains of citrated caffeine, 1 grain bicarbonate soda, % grain morphine, % o grain nitroglycerin, 2 drops INSANITY. 101 tincture digitalis, 2 drops tincture strophanthus, % grain strychnine. In addition to this he had consumed on the day preceding my first interview with him, some 3 pints of whisky. It would seem from the rapidity with which this case responded to treatment that the cardiac tonics had to some extent counteracted the depressing effects of the morphine. Another case which came under my observation was taking every four hours %o grain sulphate of strychnine; iy> grains each salol and charcoal ; 6 grains subnitrate of bis- muth ; 14 grain extract of nux vomica ; also at intervals 12 grains of acetate of potash and 10 minims spirit of nitrous ether, paraldehyde (a small teaspoonful every hour), and of morphine 26 grains in twenty- four hours in divided doses. Such cases as these are exceptional, but, as heretofore remarked, uncomplicated morphine cases are less frequently observed than in former years. The active life, great anxiety, push, work, and at- tendant sleeplessness necessitated by modern business methods are all factors in drug habituation. In states of nervous exhaustion there is recourse to alcoholics and to narcotic drugs for temporary relief. A chronic diarrhoea may have occasioned the first dose of lauda- num, paregoric, or "Sun cholera mixture." A fruitful source of opium and morphine addiction is the pres- ence of one mischievous person who is a confirmed habitue. I have known a whole neighborhood to be infected indirectly by a single individual of this char- acter. The amount of the drug consumed becomes progress- ively greater, and the system may become habituated to inordinately large quantities. From the smaller dose there is a feeling of temporary well-being. This gives 102 . INSANITY. place after a time to lassitude and apathy ; another dose is required of a larger amount, and thus from day to day the quantity is increased, the patient meanwhile making fruitless attempts at reduction. The characteristics of the chronic morphine habitue are restlessness, emotionality, irritability, brightness alternating with dullness, gaiety with moodiness. There are ineptitude for business, incapacity for mental application, suspiciousness. Nausea is a common symptom; there are painful neuralgias, in- somnia, disturbance of the heart's action and of the functions of the bowels and kidneys. The patient is unreliable and distrustful. He or she takes every means to secure the drug without the knowledge of family or friends, and becomes secretive and dishonest. It is difficult to obtain from one habituated to the use of morphine an accurate statement of the amount of the drug ingested in twenty-four hours. Treatment. Absolute rest and restraint are prac- tically indispensable for the successful treatment of these cases. Separation from home and friends is essential, both that the patient may be prevented from indulging in the habit and to thwart the injudicious at- tentions of interested and over-indulgent relatives. There should be at first active elimination by the use of calomel, or calomel and podophyllin followed by salines. Nearly all, indeed all except a small fraction of the habitual dose of the drug, may be withdrawn at once. The patient should be put to bed and for a few days receive, at intervals of four or six hours, a small amount, say a quarter to half a grain of morphine in connection with strychnine, hypodermically. By the mouth there may be given quinine, strychnine, kola, INSANITY. 103 coca, capsicum, and Jamaica dogwood as indicated. A small dose of one or other of these drugs frequently administered is comforting to the patient, and is useful in enabling him to bear the withdrawal of the more active stimulant. Let kola, coca, and valerianate of ammonia be given at one time; strychnine % two hours later ; capsicum 10 to 20 minims in two hours ; two hours later 2 grains of quinine; strychnine again in two hours ; then return to the first prescription. The patient is interested; a measure of quiet is produced and the heart action supported. Strychnine and what- ever small quantity of morphine or codeine is allowed may be given hypodermically ; the other remedies, by the mouth or bowel, according to the condition of the alimentary canal. The important point is the short intervals of administration and the change from one drug help to another. Within two or three days the amount of morphine may be diminished by one-half, and within a week the substitution of codeine may be made without serious disturbance of the heart's action. It is important to watch the latter condition and to regulate by it the ad- ministration of remedies. During the early days of treatment a hypnotic, in addition to a small amount of morphine, will be required. The one that is per- haps all round the most serviceable is veronal, but sulfonal, trional, medinal, and chloral are adapted. The average dose of veronal is about 10 grains. The patient should be kept in bed to sustain his strength. There should be warm sponge baths and massage of the extremities, particularly the lower extremities, to re- lieve the dull ache which is a constant accompaniment of the withdrawal of the drug. It is important that the 104 INSANITY. I patient should not be 'taken into confidence as to the details of treatment. He should be told that informa- tion as to what is given at any time until he is well cannot be communicated. This permits the substitu- ti n of innocuous hypodermic preparations at the time the patient expects to receive the narcotic, and although he is perhaps not always deceived, the placebo is at times sufficient to comfort him. Within ten days all preparations of opium may be withdrawn absolutely. The other remedies may be dispensed with one by one, the intervals of their use made longer, the strychnine being continued in % -grain doses four times a day. The diet during active treatment should be light and nourishing, care being taken that the stomach is not disordered by too free alimentation. Occasionally it is desirable to supplement mouth feeding by administra- tion of foods by rectum. Convalescence is usually rapid after the narcotic drugs are withdrawn.. The patient's appetite becomes good, he begins to pick up in flesh, and is able to take more and more exercise. As soon as the strength will permit, hydrotherapy, par- ticularly the cold sponging and shower, should be made use of as a tonic to the nervous system. As a rule, it is desirable to keep such patients under treatment and away from opportunities for drug taking for at least six months better for one year and three months' treatment is the minimum time in which the system may be fortified to resist the morbid craving. Once out of the toils, it is the duty of the physician to give to such a patient an open letter addressed to any physi- cian who may have his or her care in future, that there is susceptibility to morphine, and that it should not be employed except in dire emergency. It was INSANITY. 105 formerly my custom to withdraw at once morphine and all preparations of opium and trust to the use of other drugs to overcome the resultant depression. In this form of treatment, however, there is always shock to the system, and sometimes dangerous cardiac compli- cations. In my experience death has once occurred from the abrupt withdrawal. This course of treat- ment the patient insisted upon, and fearing that mor- phine would be administered without his knowledge, declined to take other medicines. In the majority of instances the rapid reduction of the drug and treat- ment as outlined above is free from dangerous symp- toms, although during its progress there are invariably more or less distress, discomfort, and painful emo- tional expression. COCAINE HABITUATION. As a consequence of the cocaine habit a psychosis frequently develops. Distinct mental perturbation occurs and hallucinations and de- lusions of persecution are common. The leading fea- tures of the condition are similar to those of alcoholic delirium, but there is greater systemic depression. In my experience there have been few unmixed cases, most subjects of cocaine having resorted to the drug to key up from the secondary depressing effects of the alkaloids of opium. Uncomplicated cases of the habit have, for the most part, arisen from the use of snuff or nasal douches containing cocaine. Treatment. In cases where the cocaine habit is complicated with that of morphine, there is, as a rule, no difficulty in the withdrawal of the former drug at once, but the patient will require for many days watch- ful attention to prevent acts of violence and self-injury and to arrest any dangerous impulses which the result- 106 INSANITY. ant delirium may create. In uncomplicated cases it is wise to administer for a few days morphine or codeine in small doses hypodermically. To overcome the de- lirium the ice-cap to the head is desirable. Other prin- ciples of treatment are the same as those set forth under the treatment of morphine addiction. Insanities from Disturbance of Function of the Thyroid Gland. Two forms of diseases bearing distinct relation to disturbance of function (lack of glandular activity) in the thyroid gland are recognized. One is associated with myxoedema. In this psychosis there are apathy, dullness of intellect, a constantly dejected mien, occa- sionally delusions of fear; there are changes in the skin and mucous membranes and in the composition of the blood which accompany myxoedema. Treatment. The treatment of this condition con- sists in the administration of thyroid extract, tonics, and medicines to promote elimination and build up the general health. CRETINISM. Another form of disease associated with thyroid disturbance is cretinism, a disease of chil- dren, rare in this country, but common in Switzerland in the mountainous regions among the peasants leading narrow lives, and where there is much intermarrying among those nearly related. There is arrest of mental development amounting to a condition of imbecility. There is complete absence or degeneration (goitrous) of the thyroid gland, sometimes associated with dilata- tion of the cerebral ventricles. The condition is hope- less as regards cure, but observers have spoken of INSANITY. 107 amelioration accompanying the continuous use of thyroid extract. HYPO- AND HYPERTHYROIDISM. There has of re- cent years been considerable discussion of mental symptoms attributable to hypothyroidism (from di- minished secretion) and hyperthyroidism (from ex- cessive secretion) dependent upon disturbances of function of the thyroid gland. Personally, I have been unable to differentiate these two conditions in their symptomatology. Both are attended by depression, anxiety, fears, apprehensiveness. The emotional dis- turbance is so profound as to readily pass over into a persecutory-delusional state. The physical sign on the one hand of thyroid diminution, on the other of en- largement, may be helpful in the diagnosis. Tachy- cardia is probably more frequent in hyperthyroidism. Both conditions are apt to occur at the climacteric period and the picture of the disease on the mental side to bear likeness to that of the presenile or involutional case. The occurrence of mental disturbance due to either condition is practically restricted to the female sex. Treatment. The treatment of these cases should be upbuilding in character, special attention being paid to any incidental debility of the heart. Thyroid extract is indicated in the hypothyroidism cases. Chloretone has been found useful in cases when great bodily dis- comfort referred to the throat and abdomen was present. It is best administered in the afternoon in three 3- to 5- grain doses three hours apart, 108 INSANITY. Dementia Praecox. As the name implies, the leading symptoms of this form of disease are due to an early reduction of brain force. There appears to be necessary to its develop- ment a hereditary tendency or the neuropathic organi- zation. Under the head Dementia Prsecox are included various cases described under the old-time classinca- tion as insanity of pubescence, insanity of masturba- tion, ovarian insanity, katatonia, stuporous melan- cholia. It is a disease of early life and a dementing* process from the beginning. As school children, some of these patients are bright and receptive, learn easily, are responsive, and show quick nervous reaction and impressionability. Others have difficulty in keeping up with their classes*. While perception and memory are good, reasoning and judgment are not correspondingly developed. They are erratic and lacking in inhibitory control. They are subject to headache and, if pressed, frequently break down in school work. They undergo attacks of dreamy abstraction and find it difficult to concentrate the attention. In some in- stances erraticism goes over by imperceptible degrees into pronounced mental perturbation. In others there is a sudden change from the habitual states of feeling and acting. This may appear coincident with the period when the boy becomes' a man or the girl a woman. It may be that the determining cause is a fever, an injury, or some shock to the nervous sys- tem. Symptoms of acute depression or excitement depending upon the form which the disease assumes occur, followed by a characteristic train of symptoms INSANITY. 109 and of which three classes of cases are recognized: the hebephrenic, the katatonic, and the paranoid. The predominant mental manifestations in dementia praecox may be those of depression, of excitement, of stupor, or there may be alternating excitement and de- pression. It is not unusual to find the attack ushered in by feelings of vague gloom during which there are perversions of sentiment, a lack of interest in the af- fairs of life, disregard for the feelings of friends and family, and incapacity for mental application. A storm of excitement may succeed to this, and this condition in turn be followed by one of stupor. In excitement the patient is disorderly in conduct, erratic, boastful, and extravagant in conversation. There are gran- diloquent delusions and suspiciousness. Periods of apparent apathy occur during which the patient, if be- lieving himself unobserved, is watchful, alert, and observant of what goes on about him. When noticed and questioned, he is silent and unresponsive. Sudden and marked fluctuations in the emotional states occur and constitute to my mind a diagnostic feature of considerable importance. Depression is fre- quently of shallow depths and there is rapid shifting to exaltation. It is difficult to take seriously a state of depression such as was observed in one case, in which there were weeping, lamentation, fear of death, then of a sudden an exclamation "I want to die," fol- lowed by the repeated spelling of the words "d-i-e die d-y-e dye" and hysterical laughter. One may discount the expression of a patient who, mentioning the un- pardonable sin and looking for death in consequence thereof, laughed, joked, and remarked if he had to go to hell he hoped to go with a smile on his face. 110 INSANITY. In the hebephrenic form the patient develops re- serve, shyness, and depression, is easily embarrassed, shuns company, is deeply religious, devotes himself to Bible study, is fussy in dress, spends much time in the bathroom and over toilet operations, is addicted to self- abuse. Later he becomes bombastic, self-assertive, and egotistic. He manufactures universal money; is acquainted with astronomy. From one state the pen- dulum swings to the other. The patient falls to brood- ing, consults various physicians, reads quack advertise- ments, becomes concerned about his bodily states and the loss of virility. Delusions of a religious character develop. These may be of the nature of exaltation and satisfaction with the spiritual state or may be self- accusatory. Passages in the Bible are read and ac- cepted by the individual as directed to him personally. He may imagine himself a second Christ. Some patients believe themselves queens, Virgin Marys; un- married women have the delusion that they have given birth to princes and kings. Occasionally the passage in Scripture in respect to the offending member is given a direct personal application, and acts of self- mutilation occur. One patient whom I knew destroyed her eyes by broken glass, following the Scriptural in- junction, "If thine eye offend thee pluck it out and cast it from thee." Another cut his tongue because of the feeling that he said things that he ought not. Still another made numerous transverse gashes on his nose. Another removed the sexual organs, believing that their retention was inconsistent with a religious life. These patients are sensational in manner and conversa- tion. They do sudden motiveless and impulsive acts, such as breaking windows or crockery, or throwing INSANITY. Ill themselves into shallow water with apparent suicidal intention. One will remain on her knees indefinitely in prayer. With this hyper-religiosity there are fre- quently eroticism and sexual depravity. One may fancy herself engaged or married, and though devoid of personal attractiveness imagine herself sought after in society. Another believes that she is insulted in thought. One fancies she has a hypnotic influence over black-eyed persons, and imagines herself sub- jected to the sight of people in vulgar situations. A young and inexperienced girl may say and do shocking things because of the presence 'in mind of evil sugges- tion. She will express with the utmost frankness and unconcern her own mental states and converse with- out shame of the sexual relation. The eroticism and egotism displayed in certain of these cases are indi- cated in the following leaf from a patient's auto- biography : MY DIARY. I am a cynic and I am only 19. So there must be something wrong somewhere. I was born a lady and of good social position, but whether I will stick to my traditions or not remains to be seen. I have had more experience than most girls of 25. I have been abroad, a year's travel and study in France with a French governess and in a French boarding school, and ten months' residence in Paris and almost three months' stay in Versailles. I have had four proposals and there are more coming, many. I do not flirt. I am a natural born egotist, cold, impulsive, fascinating (so every one tells me) to a dangerous (to me) degree cynical, heartless (be- cause I lost mine seven years ago and have never been able to regain it), indifferent to the woe I cause and perfect mis- tress of the situation always. That is the brief history of my life. I am on the threshold of my womanhood and hence the reason why I commence my diary. 112 INSANITY. Well I am in love to begin with and there isn't any chance of my falling out so far as I can can see. He is my chum's Brother and his nick-name is . What the rest is you'll never know. Well everything comes out in the wash. My mother didn't marry until she was 32 and to who was a widower with a daughter. They both had pasts. Mama had fallen in love with a man whom she had loved for five years and then he married a widow with money. Father had married a and she had gone the pace and eloped with a Jew and finally landed in an insane asylum. My sister left home when she was 18 because of incompatibility and lack of money. We were paying for a home. Bien c'est mon tour maintenant, alors je partirai pour toujours mais en pas- sant j'irai a pour restef deux mois jusque a Noel. The writings of other patients may be extremely in- coherent, as witness the following: "Have just been to supper. Did not knowing what the woodchuck was sent me here. If it did I think I am pretty well prepared to prove the cause of it and I learned it while in P too Oh no, I had forgotten it was L that told me that first and by the way I heard some one say that the papers reported him dead and I afterwards heard it disputed. I will have to dispute myself again for it was the record books being carried through the room I was in that caused me to keep a record of the way I was being worked." Another writes: July 26th Flint Mich Dear Father Received your letter yesterday It was very in- teresting I spend my time watching the squirrels. They skin the cat and do all sorts of funny things. Beth is here Lovingly The following productions from the pen of a woman in middle life, the subject of dementia praecox and in INSANITY. 113 whose case there has been during a decade no appre- ciable progression toward mental impairment, are of more or less interest : MIRRORED THOUGHTS. In days of Old. Far over the hills of Alaska Far over the hills of Spain The sun sets the same as ours and our habits are about the same. We read and consider the climate We read and consider the scenes , And wondering why God has planted In the Urtited States of America. such magazines scenes Why destruction comes into our Country Why -God has not made everything beautiful All Love Harmony Peace and Righteousness. There will be no Lightening and Thunder No Cumbustibles used in the atmosphere There will be Harmonious Music Into the clouds and everywhere In days of Old there was Noah We lived three years and ten I wonder why Doctors dont settle the climate and live it over again Kiss. Odious act Nectars Kiss, Of the most perfect lips Natures shame To grace this world. 8 j&rt* rl Jaufrm 114 INSANITY. With such a heavenly pretty face Wildest nymph oh woodland elf Nature made thy own sweet self BACHELOR LOVE. Occasionally indulging In Light Havannas And chatting affably Refreshing Ideas Precision and Exactness Of a Bachelor His mode of living His accomplishments His well organized Constitutibn His Bashful demeanor The impediment of his love It is reckoned as not durable Is refreshed by a shower And is extinct in an hour An unma-rried woman believes herself the mother of innumerable children conceived in the hypnotic state. There are superciliousness and inconsiderate conduct toward others. Various fears and obsessions occur, as that of infection, or loss of secretions through spots on the body. One applied tan shoe polish, banana skins, and apple parings to the surface to stop this loss. This patient answered questions by signs and gestures, op- posed dressing, undressing, and exercise ; would se- clude himself. He assumed constrained attitudes, was apparently indifferent, but often smiled at amusing incidents. He had delusions of conspiracy. Paroxysms of emotional disturbance occur, such as hysterical and inordinate laughter, squeezing the INSANITY. 115 throat, making guttural noises. One patient addicted to these practices believed he was secretary to the devil and had clairvoyant power. One restricts herself to a certain kind of diet. One hears messages in the tick- ing of his watch and fears electrocution. Auditory hallucinations are especially frequent. Replies to questions may be in the main rational, but there are interpolated during conversation wholly irrel- evant sentences: Question. "Are you of German extraction?" A. "My ancestors were English and Swiss, I believe. I have been told by my Aunt Emma that such was the case. You see she always had a nap in the afternoon, but I might say that my father's name is English. The family is supposed to be of English descent. There is a little Swiss mixed up in it. When they came over everyone ate a cake of soap and surviired." Q. "They didn't explode then like a geyser when they put a cake of soap in?" A. "No; they survived." There was no indication of appreciation of flying the track in either instance, as to the nap in the afternoon or the cake of soap. The conversation was perfectly serious. A knowing air passed across his face when he spoke of the nap in the afternoon as though it was rather an important communication. There was indi- cation of appreciation of the humorous side of the rela- tion of the cake of soap and the geyser. Obsessions of words which may be based upon sexual experiences in early life are tormenting and lead to irritability and impulsive acts of violence : and spite- ful remarks addressed to other people are in some cases interpretable as expressions of self-censure. (See chapter on "Symbolism in Sanity and in Insanity.") 116 INSANITY. The second form, the katatonic, has much in com- mon with the hebephrenic. The distinction between them is based largely upon the predominance in the katatonic form of stuporous states and of muscular rigidity, negativism (disposition to contrariety in con- duct), of verbigeration (the repeating over and over of words of the same or similar sound), of imitative- ness and automatism. The patient finds himself checked and impeded in various ways. With impulses to do, come counter-waves that check the exercise of the will. Patients resist attentions, such as washing and dressing, bathing, and the care of the person. They persistently oppose. One may wish to eat and come to the table fairly famished, but find himself unable to carry the food to his mouth. One avoids a rug in which there is a slight fold and steps from bare spot to bare spot on the floor. During dressing, if any- thing unusual occurs, the garment is removed and the entire process recommenced. Patients may complain of feeling light-headed and of the baneful influence of certain other people. There may be the sensation of falling. One patient was distressed by the necessity for turning at street corners ; another of my acquain- tance invariably turned back one or more times after starting from any point, and was anxious to com- municate her thoughts, but after a few words was deterred from further speaking. Disrobing operations begun at 8.30 were not completed until 11, and then the struggle came whether to retire or write letters She fancied she had brought a curse upon the hospital. One patient will stand for hours before the mirror, feeling of his muscles. Patients imitate the attitudes, gestures, and speech of others. With katatonic mani- INSANITY. 117 festations more pronounced there is increased apathy or stupor. The patient lies in bed, the head drawn, the limbs tense, the eyes closed, attempts to move him being met by muscular resistance ; or he sits for hours in a constrained position, the head thrown back, saliva issuing from the mouth, and unmindful of the calls of nature. The functions of the bowels and bladder are occasionally arrested by voluntary action (negativism). Smearing of the face and body with filth is also en- countered. This is regarded as arising from perverted sexuality. The paranoid form also has much in common with the hebephrenic. The predominant note in these cases is of egotism and boastfulness. The patient believes himself created for some special mission, to reform society, to promulgate new rules for dress and living. He may believe himself of royal birth and parentage. He affects carelessness in attire, shows indifference to the conventions, and advocates a return to the classic costumes of ancient times. One declines to take his meals with his family because of the feeling of su- periority. Impulsive acts of violence occur and the patient may be dangerous if opposed. Strange acts of which the patient is unable to give any explanation are frequently indulged in. One whom I knew started out every morning early for a five or six mile walk through a populous portion of a city carrying an empty tomato can under his arm. Another caused much annoyance to the mail carrier by filling the letter-box with buttons and rubbish. There are delusions of personal prowess and power, in some cases with undue attention to ath- letics and the eating of enormous quantities of nitrog- enous food with the idea of promoting physical de- 118 INSANITY. velopment and fitting for the pugilistic arena. Patients believe themselves gifted authors or authoresses. One can build a town a mile high, can write scientific works in various languages, is to be a commissioned officer in the Queen's army, can kill himself with autosug- gestion, thinks he can develop an additional sense. One patient I knew remarked that although Paganini compelled the worship of music-loving people, he him- self would not be satisfied with such an inglorious achievement. "That wouldn't please me just to have worldly people worship at my feet," he said, and added : "Oh, no, what I desire is to master the violin suffi- ciently to make the Lord Almighty God kneel." One of my patients conceived himself to be a second Christ, and had delusions against the Masons and Ro- man Catholics. He was intensely suspicious and once committed an assault upon another who was whistling "Follow the Man from Cooks." (He was from Cook County, 111.) This patient was subject to violent paroxysms of weeping over the deaths of eminent men. Cases which, like the following, embody the principal symptoms of both the hebephrenic and paranoid form are difficult or impossible of differentiation: The patient was 26 years of age, single, of tuberculous ancestry. He had had typhoid fever two years before. He is described as always quiet and reserved; had never been about much with other people and had held himself aloof from those who were "common" that is to say, he did not permit close contact, but had done church and settlement work among them where opportunities for patronizing and pseudo- philanthropy came into play; had had no successful continu- ous employment since leaving college, suffered from inflam- mation of the bile-duct and reached a melancholy state. He left college in the third year and came home much emaciated : could not retain a position more than four or five weeks ; did INSANITY. 119 not like the competition or strife of business; was vacillating and lacked persistence. Once he left a place of employment to attend to the wants of poor children. His head was filled with ideas of reform; there were vagrant impulses, he dis- appeared and was not heard of for a long time. When he returned he explained that he had been to see the country. He had remained much at home, having the feeling that there was no one besides himself able to care for his mother and his sister. With years he grew more and more peculiar and eventually reached the point that he did not know "what he was going to do next." He talked much of his ancestry and took occasion to write letters asserting the excellent family connection. He was delicate and showed exhaustion after slight exertion. He had been interested in psychical research. Of a sudden he developed the fancy that he should be more in company with women and had in view giving sexual atten- tion to a housemaid. Once he rapped at her door and asked admission ; being denied, he announced that he would come another day, and, true to promise, made a second call. In moral self-questioning about this episode, he consulted the minister. Later he announced to his mother: "You wanted me to do it" and claimed that he had been influenced to the act by the minister and another person as well as herself. He had the idea that people communicated with him by signs or waves ; that his mother's brother had influenced him ; that detectives were on his trail, mistakenly for his good. There were extreme indecisions and he frequently spoke of being prevented from doing what he desired. When his brother told him he must go away from home for care, he grew excited and antagonistic; then of a sudden, as is frequently noted in these cases, his manner changed and he gave consent. Between that time and actual departure, he blew hot and cold on the subject. He averted the face in conversation, was con- fused and found it difficult to express his thoughts; was introspective and had misgivings ; was undecided as to what he wanted to do and frequently changed his mind; had the impression that certain articles of food disagreed with him. The following are extracts from his correspond- ence ; . 120 INSANITY. "Just a word. When you were here I did not have a very good chance to talk with you. I have been leading such things as have been going on. In the first place, I am no friend of . He has lost his prestige, his power in , in fact he is a dead man. , however, is a gentleman. The things I have gone through in the last month were enough to drive one insane and as a student of mankind, I believe they would revolt even you. His family, however, are all right But the end is not yet. You see, I worked three years in the with Cousin , a man whom everyone respected and loved. is bound to leave this world as and he is doing all he can to promote the spirit. You see he thinks I have inherited the spirit of his brother and whether I will or not be as bound to turn into . I made a great mistake in not taking Mr. Burr's advice and going to him, telling him telling him Father is away just now and he is doubly active. I am followed by or watched by detectives whenever I am down town. He is a believer in bath houses." "Just a word. When you were here, I did not have a very good chance to talk with you. I am not a friend of who had but a few more months to live. He is a believer in family and that is what he is living for just now apparently. The reign of terror is over. is a gentleman. Was sorry not to see your mother before she went to as I wanted to help her in case there was anything she wanted down town. How is everything now . I was sorry not to hear." . Discharged from Oak Grove, placed in another in- stitution, thence discharged, he wrote as follows on March 15th: Dr. C. B. Burr, Oak Grove Sanitarium, Flint, Mich. Dear Doctor Burr: I know that you are still taking some interest in me and I thank you for it. Were it not for the fact that my heart does not stay in the right place I am sure that I could be a gentleman in spirit. Some mornings my circulation goes down and my heart INSANITY. 121 beats so feebly that the suffering is intense. Any ex- ercise sends the pulse the wrong way. I realize that my condition is not good yet I try to keep my mind on reading and other forms of mental exercise and I thank you for the help you have given me to do this. Respectfully yours . And as follows on March 22d : Dr. C. B. Burr, Oak Grove Sanitarium, Flint, Mich. Dear Sir Please forget me altogether. I get into a run down condition, feel your impulses and am weak enough to believe I can keep them Another writes as follows: June 15 1913. My dear Dr. Burr: After the Red White and Blue I am weak and faint and so so exhausted I can not get my breath please wont you have have Dr. send some thing to relieve me also please ask him to call upon me this afternoon when on this floor. Very truly yours / do not know. Sunday X Further writings of the same patient illustrate stereotypy : Please please please may I have Miss for my special nurse? I am so frightened tonight or wont wont you please come and give me a hypo? Freud has analyzed a most interesting case of de- mentia praecox showing the hysterical groundwork. Not a few cases present themselves which have at 122 INSANITY. some period of their progress offered suggestions of hysteria. Indeed, the katatonic and less markedly stuporous states may mislead the observer into a diag- nosis of this disorder. In any event, given hysterical phenomena in the early period of a suspected dementia prsecox, a search for the complex 1 may be abundantly rewarded. One believes that allusions to public characters in the daily press point to himself ; that legislation is for his sole benefit ; that theatrical performances are put on for his edification exclusively ; that locomotive whistles call him, and that gestures of others are directed to- ward him. Prognosis. Certain cases, despite the designation of the disease, seem to recover. Others improve to an extent which is* indicative of complete recovery. One in particular in my acquaintance so far recovered in appearance that he was pronounced sane by the courts, invested with the care of his property, which he turned over to the keeping of others, subsequently involving a long and expensive litigation. He relapsed in two or three months and has since been in an insane condition. In the vast majority of cases there is mental deteriora- tion, either steadily progressing or slowly taking place, there being intervals of composure and relative dis- comfort. Treatment. General principles for the care of the chronic insane govern the treatment of cases of demen- tia praecox. The nutrition must be kept up by attention to elimination, tonics, and ample feeding. Owing to delusions, the disposition to oppose, and the inhibition which the disease places upon the conduct of the pa- 1 See chapter on Hysteria, INSANITY. 123 tient,, there is occasional refusal of food to the extent that mechanical feeding is necessary. The bowels should be kept regular by laxatives as they can be ad- ministered, and by enemas. Owing to the fact that in certain katatonic cases there is voluntary retention of urine, especial care should be exercised that bladder distention does not proceed to a dangerous degree. The Russian bath and salt glow, the cold shower with sub- sequent friction, massage and passive exercise of joints which are habitually held by the patient in constrained positions, are all of value. The warm bath of several hours' duration has a calmative and beneficial effect in periods of excitement. Exercise out of doors should be regularly given, although the disposition of the pa- tient not to do may demand in some instances the ex- hibition of force. Whatever light employment he may be induced' to take will be found of service. Paralytic Dementia. Synonyms : Paretic Dementia, General Paralysis of the Insane, General Paresis. This is a disease displaying slowly increasing mental impairment, disorders of muscular movements, gastric and other nervous crises, disturbance of the higher re- flexes (inco-ordination}, and mental and physical de- cay. It is a disease of adult life and observed chiefly in those whose habits have been irregular, who have been addicted to excesses of various kinds, who have had syphilis, who have been steady drinkers, or who from -one cause or another have exhausted their nervous force. Syphilis is, however, regarded as the exclusive direct cause. The disease attacks those of high-strung nervous organization, intellectual men, 124 INSANITY. men of affairs, those accustomed to working at high pressure. It was scarcely known among women forty years ago, but later has- been more and more frequently encountered. It is a disease of middle life, but occasionally occurs in those advanced in years. It develops many years after syphilitic infec- tion and was formerly supposed to be due to nutri- tional and toxic disturbances, the remote effect of the original infection. Recently the living spirochaetae of syphilis have been discovered in the brain matter. There is a juvenile type. The disease is pathologically a meningo-encephalitis. There exist degeneration of the cortex of the brain and a low grade of inflammation of the cortex and mem- branes. Adhesion of the pia mater to the cortex is found post-mortem, and a roughened, worm-eaten ap- pearance of the cortex results from attempts to sepa- rate the pia mater therefrom. A patient breaking down with paretic dementia is at first visionary and erratic. He is full of pleasurable sensations, there is an early period of mental exaltation and marked change in emotional tone. While com- fortable if left to follow his own devices, he is irritable if opposed. He has large ideas of business, entertains impracticable schemes, and perhaps loses the accumula- tions of a lifetime in unwise business ventures or un- profitable investments or dissipates them in extravagant purchases. He gives but indifferent thought to his business and is utterly unable to fix attention upon its details. He is careless, inconsiderate, and fails to keep business appointments. His handwriting becomes ir- regular and he drops words from sentences and letters from words. When executing the finer movements of INSANITY. 125 the face and fingers he shows lack of precision. Hesi- tation and thickness of speech early occur, giving to those unaware of his breaking down an impression that he is drinking to excess. Disorders of the iris, inequal- ity of the pupils, pin-hole or immobile pupils are pres- ent. There is frequently e. lack of respect for the rights of property and appropriation of what comes within reach under the misapprehension that it belongs to the patient. The feelings are easily stirred, delu- sions develop and grow more and more extravagant as muscular inco-ordination and debility increase. The patient believes himself possessed of thousands of millions ; that he is the strongest man in the world ; that he can set out worlds in the heavens; that he is the vicegerent of God, or God Himself; that train-load after train-load of diamonds are coming to him direct from the mines; that he owns all the banks and the finest houses and fleetest horses; that in order to fly all that is necessary is to make the first attempt. One patient whom I knew took position on the sill of a second-story window and was about to take flight when intercepted. Nothing can exceed the extravagant ex- pression in these cases. I once heard a patient say that God had told him that in case of any difference of opinion between Himself and the patient, the latter should "have the say." Another made occasional ex- cursions to the sun and put copper clamps about it. Patients suffering from paresis are rarely irritable unless opposed or thwarted in their undertakings, but, inasmuch as interference with many of their projects is unescapable, friction is with difficulty avoided. They are altruistic, philanthropic, are universal in their sympathies, and cheerfully share their property with 126 INSANITY. all with whom they come in contact. One having read a newspaper account of the loss on the part of Russell Sage of $5,000,000, proposed to another to reimburse him with a check. "Oh, make it $10,000,000," the second replied. A friend told me' of the* delusions of John, a paretic patient who thought that he had died and that his soul had visited heaven and hades. Deeply imbued with many peculiar religious notions, he never lost an op- portunity to attend chapel services and invariably sat in the front row of the congregation. One Sabbath, when so placed, the officiating clergyman had selected as a text that portion of the Book of Revelations de- scriptive of heaven and the glories thereof. Suddenly, just as he was in the midst of a glowing portrayal of the jasper walls, pearly gates, and golden streets, up jumped John and at the very top of his voice bawled out: "You don't know a thing about it. I've been there myself." A paretic in a Southern asylum, expecting to be elected President of the United States, was preparing his Cabinet and parceling out the different offices to his friends. A Georgia cracker was looking on intently as if present at some epoch-making gathering. Some one present asked the paretic patient if he would not give C. some important office. Whereupon he replied, "I will make him Minister to Russia." A look of as- tonishment spread over C.'s face and he exclaimed: "Good Lord, I can't preach in my own country yet !" There is in many instances increased sexual excite- ment and the patient believes himself the progenitor of families of thousands. As time goes on the condi- tion of the pupils becomes more uniform, either habit- INSANITY. 127 ually unequal or contracted to the pinhole point. There is often a glassy appearance of the cornea. The pinhole pupil is more often encountered in cases of the neurasthenic or depressed type than in those where the emotional tone is one of exaltation. From bad to worse the patient's condition goes on, with occasional periods of remission. Seizures of an epileptiform or apoplectiform character occur. Epileptiform seizures may come in series or separately, and following them are transitory local paralyses. Apoplectiform seizures, as the word implies, are, as a rule, followed by paraly- sis of one side of the body and face, which, due to local pressure from effusion into the brain, clears up more or less completely after a few days. Death may come suddenly from a severe seizure, but oftener follows as a result of slow exhaustion after a tedious period of confinement to bed during which bedsores, dependent upon lack of nutrition of the skin, develop. Arrest in the active progress of the disease, or remissions, may take place, and a deceptive appearance of permanent improvement may be present. While quiet, no longer entertaining delusions, and having the appearance of good general health, patients in remission show pro- nounced emotional instability and incapacity for busi- ness. Occasionally the improvement or remission seems to be determined by the existence of a large, sloughy bedsore. Attention is called to the hand- writing of a patient in whom improvement occurred after an extensive slough. Toward the close of life the patient requires the same degree of attention as a little child, but so long as consciousness remains there is a feeling of strength and power. Anaesthesias, choking from paralysis of the throat, and paralysis of the blad- 128 INSANITY. der, which may result in overdistention and rupture, are symptoms encountered from time to time, and should be especially guarded against. There is often extreme friability of bones, and fractures occur from muscular action or trifling accident. Two patients whom I had under care fractured, one the femur, the other the tibia, through turning around suddenly. The movement was clumsily made in consequence of mus- cular inco-ordination and the bone snapped. In exalted cases the expression "first-rate" is frequently employed in reply to inquiries as to health, and has been called the "verbal formula of a hopeless malady." Periods of furious and unreasoning excitement are apt to oc- cur. In these, fortunately of brief duration as a rule, the patient loses all self-control, commits assaults, throws himself about, grates his teeth, and is noisy and extremely destructive. Injuries from falls are espe- cially prone to produce haematoma auris (see page 215, Othematoma). The above are the more frequent manifestations of paretic dementia. Occasionally, however, the symp- toms are those of extreme depression, and then there is an intensity, an exaggeration, so to speak, of depres- sion, which, taken in connection with the physical signs, assists the observer in differentiating the condition from the depressive insanities and from the disease with which it is more often confounded, neurasthenia. Change in the personality occurs, there is indisposition for exertion; painful sensations in the back and ex- tremities are complained of and vasomotor disturbances are present. In paretic dementia of this type there may be absence of delusions apart from those referable to the bodily states. Delusions of unworthiness such INSANITY. 129 i Jane 22, 1881. In June an extensive and indolent slough appeared on heel. a August 18, 1881. 130 INSANITY. as those observed in melancholia are not present, but there may be a feeling of so great ennui as to lead to suicidal determination and indeed suicidal attempts. Constipation and inactive liver are present. All sorts of hypochondriacal fancies based upon disturbances of organic sensation occur. There is pupillary contrac- tion or inequality, and occasionally the pupil is of the Argyll-Robertson 1 type. "Think twice," says Berkley, "before contenting yourself with a diagnosis of neu- rasthenia in a man or a woman who in middle life shows well-defined reflex pupillary disturbance. The prognosis is ominous." In paretic dementia of the melancholic quality there is outwardly less disturbance of the motor co-ordination, this owing to the fact that the patient's life is inactive and the symptoms of ataxia, always aggravated by fatigue, less in evidence. When the patient moves about it is usually in obedience to requests and with conscious exercise of co-ordination. A case cited by Berkley forcibly illustrates the danger of mistaken diagnosis. Speaking of a patient in whom transient irascibility and a tendency to forget- fulness occurred, these symptoms followed by an emo- tional state and incomplete paralysis of the left internal rectus (for which cutting of the muscles was advised by an oculist), he says: "The course was now from bad to worse. The emotional state reached such a pitch that the patient became hypochondriacal, and was sent by his family physician to consult with a medical man of note. A diagnosis of 'neurasthenia' was made, and the patient was treated accordingly, only with the result that the progress downward became more and more rapid. In the spring of 1899 mental symptoms 1 Showing accommodation to distance, but not to light. INSANITY. 131 of a character to alarm his family supervened, and the case came to me for consultation. A diagnosis of de- mentia paralytica at about the beginning of the second stage was made, and the family were warned of the progress. A few days later the man became maniacal, attempted to kill several persons, and probably would have succeeded in doing so had not all deadly weapons been removed. I elicited a history of syphilitic infec- tion ten years previously, and also of former excesses in alcohol." Summing up, he pithily adds : "Here was an almost typical case of progressive paralysis, showing all the cardinal symptoms of the disease, yet at a time when treatment might have been of some avail it was not recognized. In fact, the procedures advised, far from benefiting the patient, were, if anything, calculated to do harm." I have seen a case diagnosticated as "general nerv- ous breakdown," until the appearance of epileptiform seizures revealed the true condition. In such cases early pupillary symptoms should excite suspicion. In depressed cases the diagnosis is often further complicated by a neuralgic condition, the so-called gastric crisis, too frequently diagnosticated as gastral- gia from local causes. Attacks come on at occasional intervals without obvious cause.' The pain is exquisite and there is at times vomiting. The organic memory and organic sensation are disturbed, particularly in the depressed type, and the belief is called into exist- ence that a portion of the organism is dead or that the body is all gone. Self-mutilatory acts are sometimes committed because of the feeling that a member is 132 INSANITY. worthless and should be out of the way. Such cases as these lacking the one element which is present in the other class, namely, that of good feeling, are pitiable in the extreme. Differential Diagnosis. The differential diagnosis from the condition of pseudo-paresis, the result of pro- longed alcoholic indulgence, is in some instances diffi- cult. In both conditions there are apt to be extravagant delusions, the oculomotor symptoms, fibrillary tremor of the tongue, ataxic gait, exaggerated reflexes, and the phenomena of epileptiform seizures. A careful study of the etiology of the case will go far to clear up the diagnosis or at all events influence the diagnostician to withhold judgment until the results of treatment for a limited period of time can be ascertained. The symp- toms of pseudo-paresis due to alcohol will, as a rule, change materially within four or six weeks of quiet, the withdrawal of the habitual' stimulant, the use of hydrotherapy, employment of cardiac and general tonics, restraint, and the hospital or sanitarium regime. I have in mind at present two cases in which the resem- blance to paretic dementia was so strong as to lead to the diagnosis of the latter condition. In one there were delusions of the most extravagant type, the pin- hole pupil, indistinctness in articulation, visceral delu- sions, and marked ataxia in gait and speech. Regis says that inequality of the pupils is scarcely ever lack- ing in alcoholic pseudo-general paresis, and that per- manent hemiplegia and aphasia are more frequent and more persistent than in true paresis. The pupillary aperture is often misshapen, the pupil is dull and cloudy, and visual acuteness is lost in the alcoholic type. In the remissions of general paresis, pupillary INSANITY. 133 inequality is one of the first symptoms to disappear, while the embarrassment of speech remains in a greater or less degree. The reverse is true of alcoholic paresis. The recognition of doubtful cases of paretic demen- tia in early stages has been simplified in recent years by blood and spinal fluid examination. If a so-called positive Wassermann reaction is obtained from the blood the pre-existence of syphilis is indicated and is to that extent conclusive as to a causative factor. In recent and possibly curable cases of cerebrospinal syphilis the Wassermann is less uniformly positive than in paretic dementia. 1 The Wassermann blood test requires special apparatus and nicety of manipulation and can be suc- cessfully made only in a clinical laboratory or by one skilled in chemistry and having the necessary equip- ment. As to the examination of fluid obtained by puncture of the spinal canal in the lumbar region, if this should show the presence under the microscope of more than a very few lymphocytes 2 or of numerous plasma cells of large size, the result of the examina- tion would be highly confirmatory of any well- grounded suspicion of paretic dementia based upon psychical and bodily symptoms. Stearns says that in alcoholic paresis delusions of grandeur are persistent, and rarely change, while in true paresis these ideas change from day to day with- 1 It has been demonstrated by investigators studying the brains of those suffering from paretic dementia that there are present in these the living spirochaete of syphilis. 2 Lymphocytes and plasma cells are constituents of the blood, and, in small numbers, of the spinal fluid also. 134 INSANITY. out order or consistency. He also says that the diffi- culty in pronunciation of certain words and sentences is greater, and the fibrillary tremor more limited in general paresis than in the other condition. In both, epileptiform seizures and local anaesthesias occur, but in alcoholic paresis hallucinations of sight and sensory disorders are more marked than in paresis. In alco- holic paresis the patient frequently suffers from gastric catarrh and loss of appetite, while a ravenous appetite is almost an invariable accompaniment of true paretic dementia. Bevan Lewis says that motor impotence, not inco- ordination or ataxy, is the distinctive feature of alco- holism of the motor sphere of the cerebrum. The earliest indication of this is usually a notable degree of fine muscular tremor, implicating, in the first place, the fingers and hand, and gradually spreading to the arm ; in the next place, involving the tongue, lips, and articulatory muscles generally, and, lastly, extending to the foot and leg. The tremor is always more marked in the morning and may be dissipated by a glass of spirits ; if at first not obvious, it may often be brought out by prolonged extension of the arm, any slight voluntary exertion tending to establish it. The depressed form may be differentiated from neurasthenia by the presence in paresis of motor symp- toms referable to the eye, impairment of memory and a positive Wassermann test. Psychological Analysis : Sensation at first lively, later slow may be abol- ished. Perception false. Hallucinations or Illusions at times present. INSANITY. 135 Memory hopelessly impaired. Organic Memory impaired. Personality totally changed. Ideation feeble, irregular. Reasoning and Judgment progressively impaired. Grandiose delusions. Emotions, as a rule, exalted and pleasurable; some- times extremely depressed. Will impaired ; inhibitory control impaired and lost ; higher cerebral reflexes impaired and lost. The atten- tion is fixed with difficulty. Physical Symptoms. Progressive loss of ability to use the voluntary muscles (inco-ordination of move- ment) ; change in pupils ; constipation or diarrhoea ; enormous appetite ; lack of control over the bowels and bladder ; retention of urine ; cystitis ; bedsores ; fragil- ity of bones; convulsions or apoplectiform attacks. In Paretic Dementia there is, as a rule, tendency to suicide in exceptional cases only, but self-mutila- tion may occur, in the belief that a dead or offending member should be removed. Suicidal impulses are present in occasional cases. The homicidal tendency is encountered but rarely. One patient planned to crush another's head in a door. Another choked a nurse to the verge of complete asphyxia. Habits careless from the first, and toward the close of the disease untidy and degraded. Termination. Death. Treatment. No hope of recovery and little hope of permanent amelioration may be held out in this disease. Although syphilitic etiology is now established beyond peradventure of doubt, direct specific medication has not been found to be of curative value. The only 136 INSANITY. possibility of relief of the condition, however, lying in an antisyphilitic regime, the use of the iodide of potassium is at least in the earlier stages advisable, perhaps demanded. The patient should be removed from home to a well-appointed hospital or sanitarium where non-irritating restraint and control may be ex- ercised, the patient .prevented from squandering his means and from disgracing or discrediting himself or his family by acts prompted by the morbid condition. The routine life of the hospital, hydrotherapy, and exercise suited to the capacity and strength, careful regulation of diet, attention to elimination, and the absence of exciting or disturbing influences frequently bring about a prolonged remission in the disease. The disease process seems to be arrested and the patient's condition remains for months very comfortable. The Swift-Ellis intraspinal salvarsanized serum treatment, of late in vogue, has proven ineffectual and dis- appointing. Sleep-producing agents are often needed and of these the most generally available and best borne are chloral hydrate and the bromides. These remedies in doses of 20 to 25 grains of the former and 20 grains of the latter are valuable in the distressing complication of epilepti- form seizures and act satisfactorily by the rectum when their administration by the mouth is impracti- cable. In but one instance have I ever discovered any contraindication to their employment. In that case, one of the depressed and asthenic type with remarkable insight into the condition, there resulted cpllapse not once only, but twice or thrice, until the relation of the symptom to chloral and bromide ingestion was indubitable. INSANITY. 137 Juvenile Paresis. A form of paretic dementia affecting the young (Juvenile Paresis) was described by Clouston, in 1877, and in recent years has been brought plainly to atten- tion by Kraepelin and his school. It develops, as a rule, at or about the pubescent age, but in some cases at as early a period as the fifth or sixth year. The existence of syphilis, naturally in the vast majority of these patients inherited, is brought definitely to light through the Wassermann reaction and examination of the spinal fluid. A case at one time under the author's observation presented the following symptoms: She was said to have been bright in school in very early childhood, but at the age of 12 gradually grew dull and could not master her studies. Because of deficiencies she was not popular with her associates and became extremely sensitive. She did not enter into sports with those of her age and experienced much distress because she lacked attractiveness to those of the opposite sex. At the age of 22 there occurred a hysteroidal attack during which she opposed attentions, could not be persuaded to go to bed, displayed purposeless activity, suffered from insomnia, talked constantly, and was repetitious. A year later an attack attended by muscular tremor occurred. She could not feed herself, was ataxic, and subject to falls. These symptoms slowly increased. There developed drooping of the eyelids, stammering and tremulous speech, great emo- tional disturbance, and confusion. There was frequent outcry to "go somewhere" and she repeated over and over "Don't leave me alone," "I want my clothes," "I want to go out in the automobile." There was retention of urine as well as frequent untidiness. She was but partially oriented as to her surroundings. The temperature was slightly elevated, 99 to 100, and the pulse was rapid, 82 to 100. She was destructive to clothing and resisted attention. Some slight improvement in recognition of her surroundings occurred, but this was attended by increased irritability. Control over the lower 138 INSANITY. extremities grew 'feebler; the gait, staggering. Eventually a severe epileptiform seizure occurred. This patient showed the Hutchinson notched teeth. At the time she was lost to observation there was spasticity of the lower extremities and a tendency to contractures. In many cases such as the foregoing contractures proceed to shocking deformity. Dementia with Paralysis. This is a form of dementia produced by, and depend- ent upon, previous damage to the brain, by an apoplec- tic attack, a brain tumor, the occlusion of some blood- vessel cutting off the nutrition of certain parts of the brain, or cerebral degeneration in some of its forms. Here well-defined delusions are rare, but there are great irritability, emotional disturbance, perversions of feeling, and a tendency to misconstrue the motives of others. Brain tumor cases are peculiarly prone at some time in their progress to display symptoms which may be mistaken for hysterical. I have known two marked cases of this character. One of these in which the brain was extensively involved first showed weak- ness in walking after a visit to a friend who was par- tially paralyzed. She almost immediately developed difficulty in locomotion and this state was quite naturally attributed to imitativeness. It was a long time before the case was understood. The outlook in this disease is unfavorable. Impair- ment of the bodily and mental health is apt to go slowly on. Death may occur from apoplexy or an epilepti- form or apoplectiform seizure. INSANITY. 139 Insanity from Syphilis. Disturbances of mental operations the direct result of functional or organic brain disease from syphilis are encountered. They appear in connection with syphi- litic arterial disease, with new growths, with meningeal inflammation. In the early period of brain syphilis there may appear a neurasthenoid condition, with diffi- culty differentiable from neurasthenia proper. Occa- sionally confusional excitement occurs. Most com- monly mental symptoms of a morbid character follow epileptiform or apoplectiform seizures. They are those, as a rule, of dementia, with irritability and emo- tionality. The impairment in the memory sphere is conspicuous, and bewilderment is occasionally of that degree that recognition of the surroundings is imper- fect and the patient encounters the danger of wander- ing away from home and forgetting his name and residence. The acts of the morning are forgotten by afternoon, and the acquisition of names of new ac- quaintances is impossible. Epileptiform and apoplecti- form states attended by paresis or paralysis occur. Treatment. These conditions, being the direct re- sult of the syphilitic bacillus, are more or less amenable to methods employed for the extermination of the spirochaetae. A very positive Wassermann reaction should determine vigorous specific treatment. Manic-Depressive Insanity. Under this head are included the recoverable psy- choses heretofore designated as acute mania, subacute mania, simple melancholia, melancholia with frenzy, and melancholia with stupor, as well as the mixed 140 INSANITY. chronic form of disease characterized by alternating periods of excitement and depression, the so-called re- current mania (folie circulaire), or alternating insanity. MANIC TYPE. In the manic or excited phase of manic-depressive insanity, the mental disturbance is of recent onset and its leading characteristics are changing delusions and active excitement. Its development is usually somewhat sudden, al- though it will be found as a general thing that the patient has suffered for some time before excitement occurs from depression, emotional instability, sleepless- ness, loss of appetite, constipation, and other derange- ments of the bodily functions. When excitement ap- pears the patient becomes noisy, restless, at first irrele- vant, then incoherent in conversation, irritable, and impulsive. All grades of excitement are encountered, from extreme restlessness to complete lack of self-- control. Excitement may proceed to that degree that the patient is never quiet when awake. There are ex- travagance in speech and frequently religious exalta- tion and conversation on Biblical subjects. The patient is by turns patronizing and antagonistic. He offers large sums of money for trifling services, is conscious of great power. One wishes to be dressed in white because this color is emblematic of purity, would will her property to the nurse, denies her parents' rela- tionship to her, and conceives herself a superior being; believes she can save souls, that her touch is magical. With such extravagant fancies there may be fear of fire and assult and hallucinations of the presence of animals. One may be obscene one moment, in prayer- ful mood the next. In the midst of obscene and pro- fane talk the patient declares he is working for the INSANITY. 141 Lord. Delusions in respect to religious sects and fra- ternal orders are often mentioned. There is sexual excitement and masturbation is common. One patient I knew declared that a colored woman had given him cantharides to exalt sexual desire. Assaults are made. The patient asks for water only to dash the glass to the floor. He spits upon those who come near and is often otherwise untidy. He imagines himself charged with electricity and can shock others untd death. Psychological Analysis : Sensation is lively, impressions travel quickly, and are largely objective and pleasurable, although these may change rapidly to the painful. Perception is false. Hallucinations of sight and hearing occur ; they are usually pleasurable but are apt to change suddenly. Illusions may be present. The Memory is temporarily impaired; percepts are registered in a distorted way and inaccurately. The Organic Memory is changed ; the personality is changed, leading to delusions such as those of great strength and power, or that of a superior being. The Ideation is interrupted. Percepts come into con- sciousness one after another irregularly, are not grouped into concepts accurately, are incoherent, fleet- ing, and disorderly. Flight of ideas occurs. The Reasoning and Judgment are impaired. There is incoherence in the grouping of concepts. Delusions are of a changing character and usually pleasurable. There is frequently religious exaltation, the impression of divine command, of a call to preach and of in- spiration. Feeling. Emotions exalted and pleasurable for the 142 INSANITY. most part, but changeable as the hallucinations or delu- sions change. Volition. The will is impaired. Mental reflexes are prompt, but inhibitory control is lost or greatly im- paired. Assaults are made impulsively and blows and kicks are dealt to others because of the irregular, ex- cited muscular action constantly present. The clothing and bedding are destroyed ; the patient breaks windows and damages furniture. He denudes himself and ex- poses his person shamelessly. Erotic excitement is present. The attention is fixed with difficulty, one thing after another engaging it temporarily. Impres- sions are largely objective, and, being derived from different objects in rapid succession, are fleeting and inaccurate. There is great pressure of activity. Physical Symptoms. The circulation is rapid, the skin hot, the tongue dry and coated, eyes suffused and congested, the temperature elevated, the urine scanty and high colored, the bowels at times loose, at others costive, sleep fitful. There is rarely complaint of head- ache or other evidence of pain. There is refusal of food due to two causes: indifference, from constant activity, which prevents the patient helping himself or forbids his receiving food at the hands of another, or repugnance, because of the disordered condition of the secretions. In the excited phase of manic-depressive insanity there is, as a rule, no tendency to suicide. The habits may be untidy by reason of indifference to bodily wants and concentration upon delusions and morbid concepts. Termination. The tendency of this disease is to- ward recovery, provided the physical health can be maintained. The excitement gradually increases, par- INSANITY. 143 ticularly in those cases where early and careful treat- ment is not afforded. Within four to five weeks it reaches its height, then shades off slowly, the condition of sleeplessness being gradually overcome, food taken in better quantity and variety, the condition of the alimentary canal improved, and a better state of elimi- nation by the skin and kidneys occurring. On the subsidence of excitement a condition of depression, of emotional disturbance and weakness of will is present. There are at this time lack of appreciation of the past condition, restlessness, fault-finding, a feebleness of at- tention and of reasoning and judgment. Later, if the patient recovers, these morbid feelings disappear. Treatment. In the treatment of this form of excite- ment perfect rest should be given the patient so far as practicable, avoiding, if possible, the use of manual and mechanical restraint. The ice-cap to the head, the use of strychnine and other cardiac tonics, and reme- dies to promote elimination are of the utmost value. A course of calomel in small doses should be given at least twice a week, the bowels being kept in soluble condition meantime by the exhibition of salines and other laxative drugs, and the use of the colon flushing. In this condition there is invariably an autotoxic state to which medical therapy should be principally directed. The diet should be nourishing and liberal, the patient being induced to take, at such times as his attention can be gained, milk, malted milk, eggnog, soups, broths, cream toast, custards, cornstarch, and other light and quickly prepared dishes. Sedatives should be avoided in the daytime, but a dose of veronal or sul- fonal, 10 to 15 grains, followed three or four hours later by 20 grains of chloral, with or without valerian- 144 INSANITY. ate of ammonia or strychnine, will usually be suffi- cient to induce a quiet sleep of several hours. A small amount of exercise in the open air may be permissible, provided excitement is not increased thereby, and pro- vided the patient can be isolated from other people. The patient is, however, better if left much of the time quietly in his room under the supervision of a vigilant nurse, who will give attentions when they can be offered without contributing to excitement and will forego or postpone them when tact suggests this course. To minimize destructiveness, bedding of a non-de- structible character should be provided. Where indis- pensably necessary, to prevent rapid exhaustion and for the purpose of giving nursing attention, the rest sheet may be employed. The prolonged tepid bath of several hours' duration is of great calmative and cura- tive value in these cases. During the critical period of convalescence of which mention has been made, the patient should be safe- guarded from over-mental stimulation and be judi- ciously cared for until such time as the bodily health is fully restored and mental stability re-established. DEPRESSIVE TYPE. The reverse of the picture dis- played in the maniacal or excited phase of manic-de- pressive insanity is found in the melancholic or de- pressed phase. Here mental action is slowed, concepts and delusions are of a painful character, and vague impressions of a distressing nature put a check upon conduct. Every grade is encountered from simple de- pression, a feeling of gloom and despondency without delusions, to deep depression with painful delusions, depression with agitation and motor restlessness, or a condition of frenzy. INSANITY. 145 One may develop all of the above symptoms or in its manifestations the disease may be limited to any one to which reference has been made. Furthermore, there may be episodal or intercurrent alternations of gloom with exaltation, but the dominant note is one of anxiety and distress. 'The development of the condi- tion is slow. Constipation and auto-intoxication figure largely in the etiology. There is at first a feeling of heaviness and gloom. There is failure of attention; patients tire of their tasks easily and overlook business details. Gradually the condition deepens, the patient feels a sense of worthlessness and wretchedness, there is a disposition to shun other people and to avoid mental effort altogether. The patient is gloomy and dejected, indifferent to exercise, works only under prompting and does not carry tasks to completion. A step further and delusions of a painful character de- velop. In explanation of the feeling, the patient attrib- utes his distress to a sinful state and perhaps seeks consolation in religious exercises. These add fuel to the flame and delusions that the soul is lost, that the patient has committed the unpardonable sin, and that everything is wrong with the spiritual state, appear. "It was with inward horror," says one, "that I sank into the abyss and confronted the inevitable. I knew it with a certainty and positiveness compared with which the axioms of mathematics are the vaguest rumors and hearsay." In some cases the going over into a delusional state is determined by the injudicious talk of friends, or by the babble of faith curists and Eddyites. Character may be given to the delusions by the ill-considered outgivings of those in whom the patient confides. One 10 146 INSANITY. in a morbid nervous state was told by a so-called Chris- tian Scientist that there was no such thing as death. This she came to believe, turning it over and over in her mind interminably until the delusion that she could not die developed and suicide was attempted in order that she might make a test of the matter. Another, a refined young woman, having had erotic thoughts in connection with a painting, was told by her priest that she was possessed of the devil and a delusion was at once determined. Passages in the Bible, particularly those of a dark and somber hue, are read and pondered. One believes herself possessed by evil spirits; that she is unworthy of affection and should be badly treated ; that she ha's led a dual life; that her influence upon others is bad; that she brought sin into the world. The patient is bent upon self-chastisement or suicide. One throws herself under a moving trolley car, another takes poison, another severs an artery. One burns a finger with the idea of tasting early the torments of hell later to be suffered in their fullness. Patients re- fuse food because unworthy to take it. There are painful sensations in the skin leading to picking the face. A mother in this condition may kill her baby to save it from future suffering and commit suicide to escape an ignominious death. A condition of extreme motor agitation may appear. The patient moves restlessly back and forth, wringing her hands, moaning and deploring her wretched state. A step further and a frenzied condition comes into being. There is no rest for the patient day or night. She imagines herself burning up ; that she is being con- sumed by the fires of hell ; that poison is administered in food ; that her life is threatened in every conceivable INSANITY. 147 way. The color, red, in any fabric or decoration is pointed out as symbolic of fire. One sees herself dis- emboweled and buried alive. Sleeplessness is present ; there is loss of appetite, or at least indifference to food, and in the agitated and frenzied phases refusal of food because of delusions. Psychological Analysis : Sensation travels slowly in the simpler forms, rap- idly in the agitated and frenzied forms, and is in both instances subjective and painful. Perception is false and hallucinations of hearing and sight are present. Patients hear threatening voices and have visions of torment. Illusions may be present. The Memory is not much impaired. Organic mem- ory is impaired, the personality may be changed Undoubtedly the delusion of demoniacal possession oc- casionally present in these cases is due to disturbed visceral sensation. Ideation is particularly slow in those cases where there is hebetude and abstraction ; is rapid in agitated and frenzied cases. Reasoning and Judgment: Coherency unimpaired in the lighter phases, impaired in the frenzied phase; delusions are almost invariably present; there is a belief in unworthiness ; that the unpardonable sin has been committed; that the conduct of the patient has brought harm upon others ; that he is responsible for the sins of the world; that his family is coming to want. Emotions are depressed and painful, being depressed to such a degree at times that the patient believes him- self incapable of mental feeling. 148 INSANITY. Volition. In the simpler forms every act involves distinct effort. Inhibitory control is unimpaired. At- tention can be fixed, but the effort is wearying. Mental reflexes are slow (Retardation). Assaults upon strangers or people not related to the person are rare. Homicidal assaults are sometimes made upon children or near and dear relatives because of the delusion that want stares them in the face and that they would be better off dead than alive. There is no tendency to destructiveness. In the agitated or frenzied phases in- hibitory control is impaired or lost. There are ex- treme agitation and restlessness, and at times so great clouding of consciousness that sudden impulsive acts are made as if prompted by the impressions of delirium. In manic-depressive insanity of the de- pressed type there is a strong tendency to suicide. Physical Symptoms. In the dull and apathetic cases circulation is slow, the skin pale and cold, the tongue moist and coated and showing indentations from the teeth; the pupils are large and respond slowly, the sclerotics pearly white. Temperature normal or sub- normal; urination sometimes profuse because of in- tense emotion; bowels invariably costive; sleep fitful and troubled by painful dreams ; headache at the vertex or occiput almost constant, as a rule worse in the early morning ; appetite poor, food is refused from delusions of unworthiness to eat or bringing want upon others. In the agitated or frenzied phases there are^ disturb- ances of sensation of the skin leading to picking of the face and scalp to remove fancied insects or vermin. The patient is destructive and disorderly because of the existence of delusions. The tongue is dry and coated, and the physical symptoms very much the same as INSANITY. 149 those in the maniacal phase. The tendency to suicide in frenzied cases is extreme. Self -mutilation fre- quently occurs, sometimes in an abortive attempt to commit suicide ; again from the belief in the offending member, that the eye offends and should be plucked out, or that the presence of the sexual organs has con- tributed to the distress of the patient and that they should be removed. Treatment. Medicinal treatment should be directed to the relieving of constipation, the condition to which the autotoxic state is primarily due; to elimination by the bowels, skin, and kidneys. The bowels should be kept free by the use, two or three times a week, of calomel or calomel and podophyllin, followed by salines and colon flushing. The Russian bath and salt glow, followed by a cold shower and vigorous rubbing, are of much service. Patients should be kept in bed a large part of each day and alimentation forced. In pleasant weather a short walk in the open air is of service. This should be taken where the patient does not come in contact with inquiring friends or objects which excite anxiety or cause an increase in the delu- sional manifestations. The bitter tonics, strychnine, and iron are of service occasionally. In the agitated and frenzied states patients should be kept as much as possible in bed and carefully nursed. The refusal of food is often a perplexing complication, and tube-feed- ing will be frequently required. Sleep should be se- cured by the use of a warm bath at bedtime and a powder of sulfonal, trional, or veronal. Occasionally a hot drink at bedtime, as malted milk, or digestible cocoa, will be sufficient to induce a night's sleep with- out the aid of medicine. 150 INSANITY. CIRCULAR TYPE. In the circular type of manic- depressive insanity, there are periods of excitement, periods of depression, and at times periods of com- posure and complete lucidity. The first attack fre- quently occurs at the pubescent age, or in the woman a little later, at the age of 20 or thereabouts. Hereditary predisposition is found in a majority of cases, and from early childhood there are often evidences of emotional instability. It is not surprising, therefore, that the first symptoms should often present them- selves at the age of pubescence, during which occurs the earliest and most notable physiological crisis which the system undergoes. All powers of the mind are more or less affected. The symptoms presented vary with the stage of the malady and the intensity of excitement or the depth of depression. In excitement the demeanor of the patient may be similar to that of acute mania, but ex- citement is rarely so intense. Well-marked delusions and hallucinations are frequently absent, and there may be so perfect coherency as to deceive the inex- perienced examiner. There is extravagance in expres- sion and a high coloring of unimportant or immaterial matters. Patients of this class are fond of miscon- struing, and with the slightest basis make embarrassing accusations against others with a view of justifying loss of temper or impulsive acts. They are frequently sly and malicious and have an aptitude for sarcasm and invective and a keenness in retort very serviceable to one contesting guardianship or commitment, in mysti- fying juries. The conduct of patients during excite- ment is mischievous, and by the inexperienced attrib- utable to moral perversion. They are exasperating INSANITY. 151 and trying to the last degree, and one must keep con- stant guard upon his own temper in dealing with them. Many of the cases of so-called moral insanity are properly classified in this group. The patient desires everything in sight, spends money recklessly, borrows without provision for making payment, shows fickle- ness and change of purpose, is loquacious and incon- sistent, does not respect the rights of property. He whistles and sings to the annoyance of others, does not carry work on to completion, affects fantastic dress, is incapable of mental concentration. He fancies himself gifted as an author or orator, and there is no sense of accountability for conduct, notwithstand- ing practically perfect ability to distinguish between right and wrong. In the period of excitement the patient misconstrues motives, makes unfounded accusa- tions, sets patients up against each other, and patients against nurses. There is impairment of the inhibitory control. At times excitement reaches an extreme degree, but this is not the rule, and careful inquiry into such cases will develop the fact that periods of pro- nounced but not deep depression and brooding have alternated with those of elation and good feeling. The increased capacity for cerebral effort, the as- sumption of responsibility for the affairs of others, and the heightened emotional tone shown in the early period of excitement are well illustrated by the follow- ing letters from patients : "A strange experience in the drawing-room last evening in rather a wordy, quite unintelligible conversation with the musical voiced Mrs. . She asked me if I had ever been in . No, but I should have been, for one of my brothers studied four years at College. She had been there (she was in some haste to tell me) and knew Mrs. , and I said 152 INSANITY. my brother married her eldest daughter and Mrs. after- wards studied medicine and became Dr. of . Then she said that she herself was sent there for six months chap- eroned by and under the care of Dr. where she took lessons on the piano, elocution, etc. She also told me that Dr. was at that time losing her memory. She spoke it very delicately for that was 'the skeleton in the closet' for them all until she entered into Rest Eternal, a dozen years after, but they managed to care for her at the homes of her daughters. Then there was a rambling, one-half incoherent talk about Unitarianism, Swedenborgianism, a little Presby- terian, and also, 'piscopalianism. I could not help wondering if could not induce her to stop whispering aloud to her- self just in the dining-room, for then she would be very pre- sentable. It seems to me she has been 'cracked' by not being founded on the Rock, Christ Jesus, when she was young and plastic and then later tried to satisfy her cravings with the visionary philosophy of Swedenborg which was not made for a shallow, flattered society girl, and nothing better supplied by a strong, kind teacher. She is quite interesting to me and has made me a game of logomachy cards to take home to my bairns. She had been working all the afternoon until her head ached upon fitting down to her unsylph-like figure the new waist they had sent her from home. The smile of 'the chessy cat' whatever that critter may be, will doubtless die away especially if the glare of does its deadly work. Mrs. maid needs to be asked to part Mrs. hair with more nicety, especially in the back. Amen." Dear Dr. Burr : Please allow me to take a minute to tell you that I am fully aware that my present condition is one of "elation." But I believe and hope I shall go safely through without a "bust-up." Your kindness and the consideration extended me by all your staff are highly appreciated. I am sleeping fairly well now, have good appetite, and, of course, life has a good deal of sunshine for me just at present. As you know, about the only time I can write, or compose, any- thing worth anybody's reading is during a period of elation: so I feel as though I should "make hay while the sun shines ;" INSANITY. 153 but I do not intend to inflict much or many ( ?) of my lucu- brations upon yourself. Very respectfully yours, During the period of depression the patient is dull and listless. He lacks energy and application, is in- different to exercise, inclined to remain in bed. His conduct is similar to that heretofore discussed under the depressed phase, but there is usually an absence of fixed delusions. As excitement is less than that of the manic phase, so the depression is less pronounced than in the melancholic. 1 In proportion to the gravity of the first will be found as a rule the intensity of the second, the pendulum swinging from one extreme to the other. In depression the patient is frequently re- morseful for unpleasant acts done during excitement. Depression may shade off into complete composure and lucidity, of weeks', months', or years' duration, or on its subsidence excitement may again make its ap- pearance. Physical Symptoms. In the period of excitement all the bodily functions may be carried on normally. There is heightened good feeling and a condition of well-being. In depression there appear constipation, sleeplessness, headache, distaste for food, painful sen- sations coming from the internal organs, dyspepsia. Dysmenorrhcea is common, and gastralgia contributes to the patient's distress. There is occasionally tachy- cardia in excitement. In depression the vascular tone is low. There is complaint of pain in the head, and in the morning subnormal temperature may be present. 1 There are exceptions to this. Now and again excitement is intense and depression extreme. 154 INSANITY. Treatment. Efforts in the care of cases of this class should be directed to mitigating excitement and direct- ing muscular effort into useful channels during the elated period; to stimulating and uplifting during the period of depression. As a rule, it will be found that in proportion as this can be accomplished the symptoms of the suc- ceeding period will be ameliorated. If excitement is extreme and of long duration the succeeding de- pression will be deep and the physical forces im- paired correspondingly. Exercise, and so far as prac- ticable work in the open air, should be prescribed for the patient during elation. If the morbid energy can be diverted into useful channels much is gained. As a rule, during elation little medicinal treatment will be required. Attention to the diet may be demanded in exceptional cases where excitement is extreme and the patient uses up strength with great rapidity. The prolonged bath in the excitement of certain exceptional cases is desirable. During the depressed period the regime to be followed is like that employed in the care of those suffering from the depressive phase of the dis- ease heretofore mentioned. The bowels should be kept free by laxatives supplemented by high enemas. Diet should be of a nutritious character, and the patient's repugnance to food overcome by urging. Inasmuch as there are no delusions which impel to abstinence from food, insistence on the part of the nurse will, as a rule, be competent to overcome the patient's disinclination to eat and nutrition may be fairly maintained. While the disposition to lie in bed may be indulged in a meas- ure, a moderate amount of exercise in the open air every day should be insisted upon, and so far as practi- INSANITY. 155 cable the patient encouraged to engage in light forms of manual employment. Summing up the treatment of Manic-depressive Insanity, Dr. F. W. Langdon forcefully says: "The securing of bctth. objects (1. Protection of the patient from attempts at self -in jury. 2. Rest Physical and Mental) means, as a rule, removal from accustomed surroundings (including relatives and friends), to a hospital, where visitors and letters may be interdicted at the discretion of the physician. Many a manic- depressive has experienced an active recrudescence of a subsiding attack following a relaxation of this rule. "It must be borne in mind that the patient is sick, physically as well as mentally, and that emotional elation, 'flight of ideas,' social diversions and motor hyper-activity all mean work, mental and physical, and eventually exhaustion unless the patient gets rest and food. Diversions and amusements have no place in the acute state of the disease. Even in states of emotional depression, there is also depression of physical strength as shown by the dynamometer, etc., which is also an indication for rest. "Nutrition, including of course appropriate attention to elimination. Diet should be good, plain and liberal in variety and quantity, including a proper proportion of raw 'greens' and fruits. In case of refusal to eat solid foods, liquids must be administered at frequent intervals, by tube if necessary. Water in abundance, internally and externally is a very important nutri- tional aid. Gain in weight is an excellent prognostic indication. "Symptomatic indications, to promote sleep. In the excessively active and exhausted, nothing is so good 156 INSANITY. for this purpose as the prolonged tepid (not hot) bath (96 to 98 F.) for one-half hour to two or three hours if needed. A dose of some bromide or of sul- phonal or hyoscine may be a useful preliminary to the bath in very excited patients, but as a rule does not need repetition since the effect of the bath is so pleas- urable and beneficial that the patient takes kindly to it on subsequent days. "Other symptomatic measures include iron, when in- dicated by the blood state, various phosphorous com- pounds as lecithin, glycerophosphates, etc., for their nutritional effects. The patient who is taking full diet and proper baths, needs very little medication." "The Presenile (Involutional) and Senile Insanities. As a result of the breaking down of the nervous system due to arteriosclerosis and cell degeneration incident to old age, different forms of mental perturba- tion may appear. As in one form of manic-depressive insanity, the early manifestations may be those of ex- citement. In certain cases there are present delusional states and considerable excitement and irritability, and there is otherwise marked involvement of the emo- tional sphere. The patient is erratic, impulsive, and boastful. He decks himserf out in bizarre attire, fills his pocket with rubbish of all kinds, ties varicolored strings in his buttonhole, is loquacious to garrulity. He is intolerant of suggestion or criticism and, if angered, does acts of violence. Cared for with any lack of dis- cretion, excitement is bound to increase and may reach a state of frenzy, terminating in exhaustion. Partial recovery may succeed an attack of this kind or it INSANITY. 157 may be followed by the condition known as senile dementia. On the other hand, the leading symptoms may be those of depression. Indeed, the term melancholia has been restricted to the description of that form of mental depression which is incident to the post-climac- teric and prcsenile periods of life. The most prominent features of this condition are those referable to the bodily organs. There are visceral delusions and hypo- chondriasis. The patient believes that no action goes on in the internal organs ; that there is closure of the oesophagus; that the bowels are stopped up, and that there is not and can not be any digestion. For this reason food is taken indifferently and tube-feeding is at times necessary. The patient believes that every act of his recent life has been erroneously done. If he has sold his farm he talks constantly about the deal, re- gretting it, and insisting upon repurchase. Sometimes the insistence is so extreme that the repurchase is ef- fected at a price in advance of that of the sale. The bargain consummated, the patient is overwhelmed with self-reproach, and nothing will serve his purpose but to dispose of the property again, even at a second sacri- fice. All the time he believes that he and his family are destined for the poor-house. In the midst of plenty he avers that they are coming to want, and is worried day and night over the certain catastrophe on just ahead. Certain patients hang their bad feelings upon the most unimportant pegs. One that I knew attrib- uted all his troubles to the sale of a boat in which he was interested. Visceral delusions arising from impaired circulation and deficient innervation of the internal organs give 158 INSANITY. birth to the idea of dissolution, and the patient pro- claims incessantly that the present are his last moments on earth. Pain may be referred to the stomach, to the organs of the chest, or to the sexual organs. In one instance a terrific orchalgia was complained of, this notwithstanding no external evidence of inflammation, congestion, or change in the contour or consistency of the contents of the scrotal sac. Patients thus suffering moan and lament and are in distress continuously when awake. They demand hypnotics and secure sleep largely through these medicines. The blood-pressure in exceptional cases may be extremely high. The third condition incident to the senile state is that of dementia. There is impairment of all the faculties of mind. There are delusions, lack of appre- ciation of surroundings and extreme mental confusion. The patient is unable to dress or undress himself properly. Memory for recent events is obliterated, for remote events imperfect, and may or may not be an- nihilated. Recent concepts are not registered. There is meaningless chattering. The patient putters about and is a source of constant anxiety to those having his care by reason of the danger from falls and other ac- cidents. He is apt to be out of bed and wandering in his room at night and needs constant attention, which, however, he is apt to resist to the limit of his strength. Treatment. The general rules of treatment laid down for the care of cases of manic-depressive insanity in excited and depressed periods are adapted to the similar states in presenile and senile conditions. The bowels should be kept regular, attention should be paid to the diet, tonics administered regularly, and hypnotics from time to time as indicated. Special nursing atten- INSANITY. 159 tion is necessary for these cases to keep them 'out of mischief and to prevent injury to themselves or others. In some cases of presenile melancholia the contempla- tion of suicide is strong and, it may be regretfully added, is occasionally accomplished. Experience with a case of involutional melancholia in which blood-pressure was 200 on admission and for three months never fell below 150, the average being about 170, is of great interest because of the outcome. This patient had been sentenced to death by the home neurologist, the assumption existing of cerebral arterio- sclerosis of extreme degree. The relation between blood-pressure and the emotional states was striking and invariable. With anxiety and restlessness (she was violent and suicidal and entertained divers delu- sions, among which was that she had swallowed some- thing which occasioned intestinal obstruction, and that she had committed the unpardonable sin), blood-pres- sure promptly mounted. Once it reached 200 because of fretfulness over a change of room and again 185 for an equally unimportant reason. Lowering of blood-pressure and relief in the emotional sphere in- variably followed the cabinet bath. Medicines em- ployed were iodide of potassium and nitrate of sodium in small doses three times a day. Medication was not uninterrupted, blood-pressure readings fur- nishing indication for its withdrawal and resumption. Incidentally it is worthy of mention that laceration of the perineum was extreme and there was complete procidentia uteri. Operation was not permitted by the friends, although desired by the patient and advised by a competent gynecologist and by myself. Recovery was perfect. Had there been operation and rapid im- 160 INSANITY. provement thereafter, it is feared that psychiatry would have been denied any considerable credit for the results. Patients suffering from senile dementia should be carefully watched and waited upon. So far as possible they should be freed from annoying attentions, and whatever means necessary to be used in their care should be undertaken with extreme tact and gentleness. It is of the greatest importance that the bowels should be kept free. In most senile cases strychnine and its preparations constitute the best and most dependable general tonic. Beware of the danger of falls which often result in fractured thighs and of ruptured blad- der from overdistention. These complications are much to be dreaded. Epileptic Insanity. The complication of insanity with epilepsy is ob- served with some degree of frequency. There is slow deterioration ; and impairment of all the mental facul- ties to complete annihilation may occur. Along with intellectual deterioration there is great emotional sus- ceptibility. Patients are irritable, impulsive, and violent, and during the excitement which arises from time to time in the progress of the disease may be ex- tremely dangerous. With all the irritability, intoler- ance, and disregard for others, there is in the early stage of the disease, before mental degeneration has become too far pronounced, a strain of religiosity. Patients of this class study their Bibles with great earnestness. They are fond of employing Scriptural quotations and are critical of even the slightest moral lapses on the part of others. In institutions epileptic INSANITY. 161 patients seek the society of each other and may con- spire against the nurses. During or following the condition known as status epilepticus, where repeated convulsions occur in the course of a day or several days, a prolonged period of confusional excitement may occur. At such times the patient is highly dangerous. The epileptiform attacks in Paretic Dementia may be mistaken for true epilepsy. A rare condition, narcolepsie, characterized by overwhelming somno- lence may also appear to be petit mal. Treatment. In the care of cases of epileptic in- sanity, the bromides and tonics must be depended upon as a regular prescription for the allaying of nervous excitement. Exercise in the open air, safeguarding the patient from injury and from accident due to falls in perilous situations, should be given. During status epilepticus and epileptic excitement the patient is best cared for in bed, withdrawn from all exciting incidents and anything calculated to arouse a nervous reflex lead- ing to pugnacity and damage to property. During the occurrence of frequent seizures, chloral hydrate, given in 20- to 25- grain doses, with an equal amount of bro- mide of potassium, once in three or four hours, as necessary, is often of great value. Psycho-neuroses and Neuroses. HYSTERICAL TYPE. The unchecked impulses of the hysterical patient may become to such an extent habitual that a true insanity develops. The acts of disorder, noisiness, and destructiveness so prominent in these cases are due to impairment of the will and inhibitory control. There is absence of delusions 11 162 INSANITY. properly so-called although the patient may feign their existence. The leading features of the insane condition resulting from hysteria may be of the maniacal or the melancholic type. Patients are extremely imitative and are apt to do what they see other patients about them doing. Later on, with ex- citement, there are the usual physical signs of hysteria, the pallid countenance, flushed only during active mental disturbance, the cold, clammy hands, the re- laxed and perspiring skin, the dilated pupils, the sen- sation of a ball in the throat. In the depressed form patients are extremely emotional; they weep easily, they suffer, in fancy or actually, much mental distress ; they are incapable of exertion, they permit their limbs to become contractured from disuse, they present paralysis of motion and anaesthesia. Terrific attacks of vomiting and strange vasomotor disturbances of the skin may be present. Such patients are without delu- sions aside from those which strictly pertain to bodily sensations and movements. They are not, as a rule, suicidal, but often threaten suicide, and one may under strong impulsion seize a favorable opportunity to de- stroy herself. I have known the approach of a train of cars to furnish this opportunity to one who I have every reason to believe was not seriously contemplating self-destruction. It should be remembered further that acts committed for the purpose of exciting alarm or sympathy and not intentionally suicidal may result fatally. Hysteria may simulate meningitis, acute maniacal conditions, or epilepsy. A case of considerable interest from a diagnostic standpoint is the following: INSANITY. 163 The patient was 16 years .of age, single, a student, and of good heredity. He had been delicate, had had otitis media when a boy, and repeated attacks since. Ten years before coming under my care he had septic infection of the lymphatic system of one arm. There was suppuration of the glands, several of which required to be removed. In the preceding January, he had a severe attack of scarlet fever, which was followed by quinsy. Convalescence was slow, and he failed to regain strength. One day, when sitting at table, he com- plained of feeling ill, and, suddenly seizing his head, screamed with pain. The physician who reached him a few minutes later found the head and upper trunk intensely congested and the extremities cold. There was extreme photophobia, and for two weeks he was confined to a dark room, a compress covering the eyes. He improved, but a few weeks later, returning from a drive, had a similar attack. In this one he fell to the ground, and the nurse in attendance reported to the physician that she believed that he had had an epileptic seizure. The photophobia returned, and reappeared at irregu- lar intervals after that time. There were attacks simulating petit mal, the face wearing a blank expression and momentary unconsciousness apparently occurring, but certain symptoms preceding attacks led to the suspicion of a strong emotional element. During the attacks he was restless and confused, and moaned, cried, and talked deliriously. The opinion of the specialist called in consultation was that meningitis was threatened. Later there was complaint of pain in the stomach, and at times the locality of the pain suggested appendicitis. Following an attack three weeks before admission to Oak Grove Hospital he had aphasia, and a paretic condition of the entire muscular apparatus. He was unable to pick up articles or to write. Cerebration was much delayed, and the reflexes were slow. There was elevation of temperature. Constipation was present. It was feared at the time he came under treatment that a dependence on morphine had been established. He had required a small fraction of a grain daily, was subject to emotional storms and attacks of pain, and this agent seemed to be required for his relief. None was given him at the hospital, however. After resting in bed for a time with the ice-cap .to the head he grew quiet, 164 INSANITY. and the night after admission, but for a hysterical attack, slept well without medicine. One night only he was wakeful and required a hypnotic. A note made two weeks after admission states that there have been no unfavorable symp- toms since the first twenty-four hours, and it is believed that the hysterical outbreak of the first evening was due to the injudicious attention of a nurse who came with him, and whose stay was insisted upon by the patient's friends. The case emphasizes the importance of change of environment in such cases. At home the attention the patient received was fussy and injudicious, and altogether disproportionate to the actual requirements. The condition was evidently aggravated also by a degree of eroticism toward a woman nurse in whose care he had been placed for several months. Brain tumor cases are prone to display some time in their progress, symptoms apparently hysterical. A hysteroidal state developing as a result of battle is discussed in the footnote, page 33. Much light has been shed in recent years on the mechanism of hysteria through the researches of Freud and those of his school, who attribute the oc- currence of the psychical explosion which characterizes hysteria to suppression of some experience of early life occasioning trauma (injury) of a sexual character. The suppressed recollection of something which for the moment made profound impression, the defense against the recollection induced by modesty, humiliation, self- censure, or convention occasion a subconscious smoldering which under favoring circumstances bursts into flame. The muscular agitation, the loss of self- control, the bizarre movements, the outcries, the con- vulsive phenomena, are prompted by subconscious im- pulses. Even as there is eruption of the volcano when pressure within exceeds resistance from without, so self-control is lost and erratic and erotic acts take place. INSANITY. 165 One may refer to pain in the abdomen, as in a case which came under my observation, and demand mor- phine and other sedatives for its correction, translating a purely erotic fancy developed from sexual indiscre- tion into actual pain. Another, asked to communicate in detail a visual hallucination, spoke of a fish bearing the head of a man swimming toward a woman's sexual parts. The outgivings of the patient in reference to this symbol were those of an unusual sexual experience which had evidently occasioned much self-censure. Through the revelation of that which had fretted and distressed, the hysterical symptoms were completely relieved and recovery speedily followed. In this case the bounds of ordinary hysterical unrestraint had been far exceeded. There was an acute delirious condition accompanied by visual hallucinations and frenzied ex- citement. Refusal of food had led to emaciation and debility. Suicidal impulses were present to an extent which necessitated close and constant supervision. PSYCHASTHENIC TYPE. Closely allied to hysterical or hysteroidal cases are those showing besetments or obsessions and dual personality. Morbid obsessions are of every kind and degree. They pertain to the health, surroundings, and circumstances of the patient. They interfere with his uprisings and downsittings, and are senseless and absurd, but they cause the lives of those they influence to be to the last degree wretched. Tormented by doubts, hesitant in performing acts, with possibly unimpaired judgment as to the' proper course to pursue, such patients vainly battle against the hor- rors of the bondage they feel, and are deserving ob- jects of commiseration. To one class of the obsessed pertain those who are constantly exercised by the 166 INSANITY. necessity of inquiring into the whys and wherefores of everything in life. The smallest matters are minutely analyzed, the most commonplace things are subjected to rigid inquiry, and the patient is in more or less fre- quent anguish because unable to come to a satisfactory decision upon the subject presented to his mind. This may be an extreme exaggeration of a disposition dis- played by certain neurotic children to catechize upon commonplace matters to the limit of their elders' en- durance. Others are deeply concerned over religious matters. They fear that some essential religious ob- servance has not been met and that, in consequence, a sinful state has developed. Others, still, are beset with fear and feel baseless and unreasoning alarm from the elements, objects, places, and diseases. One whom I knew thought that blood flowing -from a cut finger would harm those who came near and believed that whoever was in the direction toward which her hand pointed when putting on her sleeve would be harmed. One patient is compelled to count the squares in the pavement and the trees by the side of the walks; another gives utterance to oaths and vile language. One whom I knew betrayed no other evidence of dis- ease, aside from general reduction in mental strength, but was beset by an impulse to kill his wife and had sharpened a knife for that purpose. Another patient under my observation, with perfect realization of his condition, had impulses to strike and dreaded the time when he could no longer resist them. One form of be- setment is the aboulic. There is absence of will. A patient under my observation suffering from aboulia described her condition as follows : "The first great trouble of my life occurred about nine years ago, when I lost by death a beloved child. Two years later, a INSANITY. 167 little son was born to me. I was far from strong then, and it was during this pregnancy that I had my first sinking spell ; it was of course attributed to my condition at the time, but they have occurred with more or less frequency ever since. Latterly, there has been a longer lapse of time between the spells, and not so severe. When my baby was one year old, death deprived me of both father and mother in the course of six weeks, and this, added to many family troubles arising at that time, I think is the direct cause of my illness, although I do not think my disease reached its climax until four years ago, when I had a miscarriage. Since that time it has been impossible for me to recover the mastery of my nerves and self. My condition at present, I think, is more hopeful than morbid, although I have hours of exaltation and very many of depression when I feel that I will never get well ; in fact, only become worse as the years roll by. My un- happiness consists more in the fact that I am unable to contribute to my family's happiness than on my own account, for I think I could easily accommodate myself to circum- stances. "My nervousness takes several forms. In an undefined dread which makes me feel unsafe when abroad, when at the homes of my friends or shopping, which when persisted in by me as a means of cure, causes untold mental suffering, introspective reasoning, faintness, general restlessness, and intense pain of all the nerves covering the entire body, but severest in the hands and knees. This condition is the same while entertaining in my own home, not usually so severe, but is present more or less all the time, although at home I am more able to control myself on account of the feeling that when my powers of endurance give out, I can retire to the privacy of my own apartments and send for a physician when necessary. I do not mean to state the following in praise of myself, yet, I have been able to fight these unusually well. I merely state this fact, for I have often been told it was only imagination on my part and that if I would only exercise a stronger will-power, I could do much to help myself. These pains in my knees, which I spoke of before, are very severe at times, and always accompany or follow a restless night or 168 INSANITY. worry of any kind. The other forms of nervousness are a longing to cry at times, weakness of limbs, and trembling. "I have no physical weakness to complain of. For a time, I supposed my heart weak, and thought each sinking spell meant death. I overcame that fear, and am only rarely troubled with palpitation. Appetite good, sleep fairly well, and am quite accustomed to being told I look well, yet I feel far from strong, and am tired to exhaustion most of the time. I often wish I had absolutely nothing to do, no responsibilities ; and yet, I have found that by keeping myself very busy, I can ward off a nervous attack." The obsession may be, as in one case under my care, of the swallowing or having swallowed some deleteri- ous substance as pins or needles, or that in some way or other all lost pins and needles made their way into her stomach. Obsession of words has been discussed at length in the section on "Symbolism in Sanity and in Insanity." Other forms of obsession are closely related to manic-depressive states and to dementia prsecox. The leading feature of these cases is horrible and persistent fear. In one case it was that of pursuit by electricians, compulsory marriage, and conspiracy in which her brother was involved. There was also fear of conta- gion and of sexual assault. She heard disparaging remarks as coming from distant voices which accused her of having a bad disorder, had an impression of being infected from a stool in the water closet, and thought to prevent sexual assault by wearing a rubber bag over the pelvic region. She believed herself re- sponsible for trouble about to come upon her family. A young woman, a bright student in school, of a highly religious turn of mind, was advised by an Evangelist that a young man who was interested in her was not a Christian and that if she married him she would have a soul on her hands. INSANITY. 169 She sustained several attacks of hysteria, one incident to attendance upon revival meeting. There were disturbance of attention, confusion, and self -depreciation. She received sug- gestions from different articles of food. "If I eat that onion," she said, "and know that several other people eat them at the same time, they would all have the same train of thought and all would know that I was menstruating." Cocoa and chocolate suggested negroes; poached eggs 1 on toast, the minister who had conducted the revival services. Certain experiences which she did not mention indicated strong sexual temptation and delusions growing out of them were that her spiritual nature had been destroyed. Improve- ment in this casq grew out of confiding in the nurse and to some extent in myself and the suggestions to treat as common- places the matters which had weighed so heavily upon her mind. In the psychasthenic group naturally fall certain cases of peculiar and shut-in personality. While ordi- narily bright in school, the social side is undeveloped. Introspection is obvious but it is difficult to obtain revelation of what is going on in the mind through lack of responsiveness. Such are silent, aloof, do not join in the pastimes of others. They avoid house- hold avocations but may be facile in some sort of hand-work. Hesitations are prominent, also un- punctuality and failure in obligation to others. Apathy and indifference are conspicuous and con- tinuous efforts on the part of others is needed to sus- tain conversation. Fatigue and the appearance of boredom follow attempts in this line. There are fre- quently religious doubts and misgivings. Dual Personality. Dual personality is at times en- countered as in the following cases : 1 See section on "Symbolism in Sanity and in Insanity.' 170 INSANITY. For two years before the patient came under my observa- tion she was said to have had no recollection of incidents, although able to carry on her work and participate in the affairs of the household. During the first attack, two years before, she came to the table clad negligently, was dull and confused, appeared drowsy, and in the evening stuporous.. The same night she became delirious and appeared to bt resisting and fighting her mother (from whom she had been separated). She opposed attention and refused medicine. She assumed grotesque positions, such as hanging over the foot- board of the bed with lower extremities on the bed and arms on the floor, or hips on the bed rail and shoulders and back on the floor. There were also opisthotonos and cata- leptoid states. At the end of ten weeks she was much im- proved, but her manner became entirely changed. From being amiable she grew wilful and acted in opposition to the wishes of her friends. There were attacks of grave hysteria for months afterward, when suddenly a change occurred. She felt something snap in the left side of the head and ap- peared as if waking from sleep, inquired how she came to be upstairs, and remembered going to sleep on the couch in the sitting-room, an event which occurred eight months before. There appeared to be obliteration of recollection of events during this time. A kodak which she had learned to use very skilfully was entirely unknown to her, and she ap- peared to be unable even to open the case, which was operated 'by means of a concealed button. Persons with whom she had become acquainted during the period were as perfect strangers. It was impossible to convince her that it was summer season until she was taken to the window and shown that there was no snow on the ground. Occasional hysterical attacks oc- curred subsequently. During the attacks she struck her head against the wall and it was often necessary to use force in controlling her. She tried to bite and would repeat petu- lantly, "I will kill myself." Later her conduct became girlish and romping. She took childish delight in riding her bicycle at high speed. There was at no time any evidence of paralysis. Another patient took the midday meal on Sunday with a relative. She appeared well. Three hours later she was in a. INSANITY. 171 state of mental confusion which seemed to develop at a reli- gious meeting. The next day she was found on the street bewildered 'and lost. She thought she was in Pittsburgh. Recollection of Detroit and of previous acquaintances and in- cidents had been obliterated. She was quiet, dull, and con- fused. She made new associations and relearned the names of friends. She wept easily, assigning as a reason that she could not think. She received telegrams, one saying that her father was ill and asking an appointment with her in Canada. Her friends had no knowledge of any person of the name signed to the telegrams, and it was conjectured, rightly,, as subsequently developed, that she sent them to herself. Fugues. Cases like the foregoing in which there is sudden flight or confusional wandering with complete failure of orientation as to time and place, the so-called fugues, are of very great interest. Appearing in the youthful subject, they are, in the opinion of Jung, the substitute for a sexual impulsion. That they are in- variably due to some suppressed emotional strain is altogether probable, but this need not be of sexual quality, as the following case illustrates : A young man 28 years of age who had sustained injury to the eyeball fifteen years before (an injury which subse- quently necessitated enucleation), of hereditary tendency to mental disease, of good habits, industrious and serious- minded, suddenly left his business and disappeared as com- pletely as though lost in midocean. Ten days later, he was found by a native boy on the bank of a creek in the interior of Cuba. He was lying on his back, his face blistered by the broiling sun. Much longer exposure must inevitably have resulted in death. The native boy roused him and gave him directions as to how to proceed. He walked during the balance of that day and the following night without food, finally reaching a park in Havana. There he was identified by a passerby as a fellow-American and taken to the Consulate, where provision was made for his immediate necessities. Not then or at any time afterward had he the slightest recollection of the incidents of travel. 172 INSANITY. In this case the so-called "complex" (the deep, subconscious, subtle association which determined flight) did not appear until three years later, when in consequence of business irregularities skilfully concealed for a long period he again fled to avoid exposure. A man in the sixties, of scrupulous integrity, who had permitted himself to engage in a business trans- action having a shady appearance, became greatly concerned and fled from home. He was absent dur- ing an entire night and when found in the mid-fore- noon was standing waist deep in the water of a lake, holding an umbrella over his head. He was utterly confused and his condition pitiable, but the recollec- tion on the part of his discoverers of Dick Swivel- ler's observation to the Marchioness that "an umbrella might be useful in case of fire," lent to the scene a comedy element. Anxiety Neuroses. Related to the hysteric and neurasthenic states are the anxiety neuroses. The leading characteristic of these cases is, as the name in- dicates, extreme apprehensiveness. Delusions properly so called are non-existent. The patient is, however, in more or less constant fear of loss of self-control and of death. Dread of doing, anxiety over the pos- sible result of effort, concentration upon the sexual apparatus, fear of impotency, pallor, flushings, sudden perspiring, distress in the region of the solar plexus^ are accompaniments of this disorder. It has been at- tributed (erroneously, no doubt, in many cases) to cer- tain departures from the normal in the sexual life. In the following case after years of acute suffering the patient was relieved by abdominal surgery. His own INSANITY. 173 account of the condition and the results of surgical care are most interesting: "It will perhaps be of some interest to you to receive a few lines from me on the subject of my experience since my return here, though both Dr. and Dr. have probably fully advised you as to the technical features of the operation performed on me and of its happy and truly astonishing results. "Soon after my arrival here, Dr. suggested a further X-ray examination. This was made and disclosed a marked drop of the stomach, a condition which Dr. seemed to regard as among the principal disturbing factors in my case. Dr. however desired a more or better denned outline of the lower bowel and accordingly still another X-ray examination was made on the day preceding the operation. This revealed a very much mixed up condition of the sigmoid section of the colon, the particulars as to which you have probably obtained from Dr. . The existence of an excess of about 18 inches in the colon at that point, and said to be congenital in its origin, presented a rather pecul- iar and perhaps exceptional condition. "It was a case of worrying about a surplus rather than a deficit. In the course of the operation it was discovered that the appendix didn't look any too good and its removal has disposed of any possible cause for alarm in that direction. All these features, taken together with the kink in the transverse section of the colon, as revealed by the X-ray examination made in , presented a father large area for the surgeon's work and necessitated a long horizontal in- cision across the lower part of the abdomen as well as a diagonal one from the region of the stomach to the lower right bowel. It is perhaps due in part to the character of the incisions that I was left quite sore and highly sensitive to the slightest movement for quite a time after the opera- tion. Indeed the first four or five days I was very sick and generally miserable, so much so that I don't think I shall ever resort to ether in search of a soothing influence. "All the pain and discomfort, however, resulting from necessary surgical injury were very soon and almost en- 174 INSANITY. tirely lost in the otherwise happy results of the operation. In so far as the former symptoms of great distress, fear, anxiety, and morbid speculation, etc., etc., are concerned, they have practically gone. I need not rehearse the past symp- toms, which represented to me the full measure of human wretchedness and which totalled a feeling of absolute hope- lessness, in order to emphasize the feeling of composure and restfulness and even cheer which has come to me, to all of which I was a stranger for so long a time. True, I am not as yet doing any athletic stunts, being still very weak and much reduced in weight. I am gaining, however, in that respect, though very slowly, from day to day. Though un- prepared as yet to resume my accustomed duties, I am pre- paring to leave for my home today, where I shall spend some time in storing up further strength and in putting a little flesh on a normally lean and lank figure but I leave here in the realization that the controlling cause of my past troubles has been removed and that I may expect to be back on my job before very long. My appetite is good even keen at times. My stomach is acting very well and the colon seems to realize what is expected of it, as I am taking no laxative only what is called vaseline oil prescribed by Dr. to promote the desired action. In fine, unless I am very much deceived, I shall forget a harrowing past in dwelling on the old German phrase 'Ende gut alles gut.' " At times the obsession of fear in the mind of a patient is related to quite a different perhaps com- monplace and absurd matter, from that which originally inspired it, as apprehension of perpetual in- somnia in one who years before had lost sleep through dwelling upon the possible consequences of a sex transgression. This is a convenient, innocuous and perfectly creditable and ethical peg upon which to hang the suppressed painful emotion and at first per- haps consciously was later unconsciously substituted therefor. Eventually it became a morbid habit of INSANITY. 175 thinking and had all the strength and defimteness of a reasonably founded fear. Treatment. In the treatment of these conditions the most important desideratum is the withdrawal of the patient from the surroundings and circumstances under which emotional control is with most difficulty exer- cised. Hysterical and obsessed patients are best cared for away from home in a sanitarium or hospital, where the daily life can be in every respect regulated. A nutritious diet, and the modified rest cure, massage, hydrotherapy, and a tonic regime are necessary. The bodily health should be built up and little by little the emotional control re-established, by work suited to the individual's capacity and strength, and by gentle sug- gestion and encouragement. In this work of restora- tion of nervous and emotional tone, months or years may be necessary. The uncovering of the complex where this is prac- ticable with the so-called mental catharsis (unburden- ing the patient's mind and bringing subtle emotions into the open) through the methods of psycho-analysis is, as already indicated, of the utmost value in selected cases. The happy results of surgery in the above case emphasize the desirability of X-ray examination and the relief of visceroptoses when this is practicable. Idiocy and Imbecility. These are mental defects from congenital causes or arrest of development in infancy. In Idiocy there is complete absence of mental action, the operations of life being purely vegetative. Imbecility is of all grades: from that which is ex- treme up through the so-called defective and Moron 176 INSANITY. types to paranoia, the highest form of congenital mental infirmity. The higher grade imbeciles are classifiable under certain arbitrary intelligence tests as the Binet-Simon. Imbeciles are lacking in self-con- trol, are irritable, impulsive, mischievous, and imita- tive of improprieties. The higher faculties of the mind are feebly developed. Powers of thinking are circumscribed. The emotions of imbeciles are easily aroused, and inhibitory control is feeble ; consequently, they often do acts of violence. Imbeciles, as such, are not proper subjects for treatment in institutions for the care of the insane measures adapted to them being more of an educational than medical nature. Imbeciles, like sane people, however, may become insane. Paranoia. Paranoia is a form of disease occurring in one of congenitally -defective nervous organisation, and marked by certain well-defined symptoms which seem to be due to defects of development, and frequently appear as an exaggeration of natural characteristics. One suffering from Paranoia is from childhood somewhat peculiar. He may be bright and receptive in certain ways, may learn readily in school, but shows eccentricities of conduct; is self-conceited, introspec- tive, and develops unsymmetrically. Without obvious exciting cause, or with some slight cause, as a fever, a trifling injury, or a disappointment, he becomes suspi- cious. This feeling is usually at first vague and indefi- nite. Mental depression may proceed to a considerable degree. There are associated with it, however, no fixed delusions of unworthiness, or of poison, as in the depressed phase of manic-depressive insanity, but INSANITY. 177 vague ideas of conspiracy and disposition on the part of others to deprive him of his property or business rights. A business failure, perhaps, which has been the natural outcome of loose methods and indifferent application, is charged up to the machinations of those inimical to him. 1 This is the so-called "persecutory stage." Following this is what is known as the "transition stage." Some event may occur in the patient's life a visual halluci- nation, a vivid emotional experience, a dream, a fortui- tous circumstance, a casual remark by another, or the encounter of a passage in reading which may furnish to the patient a key or clue to the mysteries surround- ing his past career. He begins then to see that things have thus been planned out for him from the begin- ning; that he was to be brought up by those claiming his parentage, to conceal his noble birth; that he is a prophet, or even Christ. He diligently cons the Scrip- tures for references to himself, and finds in this pass- age and that the prediction of his coming; of the persecution to which he will be subjected; of his ulti- mate triumph. He sees now the reason why he has been persecuted in the past. It has been because of the envy of others, or because those who knew of his mental gifts or his true social position desired to keep him from coming into his inheritance. One patient conceived the idea that a large branch factory in which 1 1 once knew a patient who, in this condition, enlisted in the army. He felt himself watched and checked in his laud- able undertakings on every hand ; he believed that the generals of the army Sherman and Grant were conspiring' to keep him in the position of private, and prevent his meeting that reward in promotion to which his abilities and meritorious conduct entitled him. 12 178 INSANITY. he was employed as foreman built for the purpose of producing a line of inexpensive vehicles was con- structed and organized for the sole purpose of his humiliation. Another believed that the institution with which she was connected parodied her life. The logical sequence of this delusion was difficult to obtain, but the idea seemed to be that, because celibacy was enforced therein, she, being unmarried, was naturally adjusted to the condition. A patient admitted to the clinic in Munich eleven years ago brought with him massive volumes in manuscript decorated with hieroglyphics and symbols indicating divine inspiration. He was the spiritual head of a small religious sect, similar' I dare say, to those founded by the notorious Schlatter and other self-appointed ministers of the Lord. A very common delusion is that of proprietorship in an in- stitution in which the lot of the patient may fall. He accepts confinement and restriction as a part of the magnificent scheme of his life, and adjusts himself to the hospital routine, the environmental horizon being just sufficiently near and small to give outlet to energies and avert the confusion, friction, and irritability inci- dent to contact with more active minds. It is not difficult to see in the foregoing a description of the cranks of the world the "harmless insane," the physician's office-oore, and the neighborhood nuisance. The usual quiet conduct, the continued application to business, the ability to converse rationally on current, topics, the bright memory, the logical method of presenting beliefs, the habitual volitional con- trol, frequently deceive as to the true nature of the patient. INSANITY. 179 As a matter of fact, the so-called cranks, of this de- scription, constitute a dangerous element in society. They are apt to make sudden homicidal assaults in con- sequence of delusions. 1 Many of the assassins of dis- tinguished persons have belonged to the paranoiac class. Dementia is non-existent in these cases. 2 Some re- tain until late in the disease tolerably full possession o^ their original power to think correctly, except in the line of their delusions ; to reason upon subjects foreign to themselves; to recollect perfectly; to acquire new facts, and even to display ability in the line of con- struction or invention. The foreman of the vehicle plant to whom allusion has been made was a most accomplished and efficient workman; Mr. F., a paranoiac, who was committed to a South- ern hospital on account of persistent efforts to marry a certain young lady, was very much disturbed on ac- count of his confinement, and not being able to see his lady love. The superintendent and a friend of Mr. F., in trying to console him, suggested that "there were others." 1 They believe .that in committing acts of homicide they are benefactors of society. Thus: CHICAGO, December 8. Prendergast, the assassin, made a formal protest against the plea of insanity being introduced in his case today. When he was led into Judge Brentano's court room, he handed his attorney, Mr. Essex, a letter in which he asked that the in- sanity plea be withdrawn, declaring that he believed people will get an idea that he did not kill Carter Harrison for the benefit of the people at large, but rather from a personal or selfish motive. Attorney Essex declined to state whether he would give the letter any consideration. Press Report. 2 See the "remarkable letter," page 182. 180 INSANITY. The superintendent said: "F., there are too many women in the world to go daft over one and you should follow my example. When I was courting, if one would not have me, I simply dropped her and tried another, until finally finding one who would have me." The friend of F. said, "Yes, that is right; that is the way I did." F. very coolly remarked: "That might be all right for you two, but I am a little particular about whom I court." Cases of paranoia will frequently offer much diffi- culty in diagnosis. Owing to their litigious propensities and the disposition to make sudden assaults in obe- dience to delusions, paranoiac patients are especially prone to get into court. The examiner will find him- self under the necessity of analyzing symptoms care- fully and formulating a conclusion which clever and close interrogation will not disturb. In paranoia one has to deal with the evolution of the crooked stick. Such patients grow up to be insane. They are more or less erratic from childhood, and the point where crraticism passes over into irresponsibility may be diffi- cult to determine. These patients are extremely sus- ceptible to outside influences, are impressionable, and those from the lower walks of life, from which their numbers are largely recruited, prove the ready tool of anarchists, revolutionists, and those who would subvert social order. In the early stages of the malady there are persecutory delusions, and in consequence of these, dangerous tendencies suddenly develop. Reasoning may be of a logical character, and the delusions not intrinsically unbelievable, as, for example, that a hus- band known to be consorting with lewd women is at- INSANITY. 181 tempting to poison his wife. If, however, the wife should express the belief that poison was administered by shaking garments in her room, or that it was mailed to her in papers dusted over with impalpable powder, its essentially delusional character would be apparent. The medical examiner should preserve an open mind and not permit himself to be misled by the apparent reasonableness of what are, in fact, but morbid sus- picions. Psychological Analysis : Sensation unaffected. Perception unaffected, as a rule. Occasionally hallu- cinations occur. Memory unimpaired. Organic Memory and Personality changed. Ideation unimpaired. Reasoning and Judgment. No incoherence in group- ing of concepts, but, reasoning from false premises, a logical delusion results. Emotions, in persecutory stage, painful ; after transi- tion period, as a rule pleasurable. Attention unaffected. Will unimpaired. Reflexes unimpaired. Assaults, if made, are because of delusions of conspiracy or fraud. Physical Symptoms, immaterial. There is frequently a distinct lack of symmetry of the head. There is rarely any tendency to suicide. Exceptional cases, however, are extremely suicidal. The habits are tidy. Termination. ^Chronicity. Treatment. The general principles outlined in Parts IV and V of this work apply to the treatment of para- 182 INSANITY. noia. Employment is of the utmost service, and under the hospital regime much valuable work may be ob- tained from these patients through the tactful guidance of energies, which would otherwise be largely mis- directed, into useful channels. A remarkable letter from one of high cultural at- tainments suffering from paranoia. Dear Nearly ten months have now elapsed since the receipt of your last letter that of November llth, 1918. I fully in- tended as I told you to write more minutely as to my state of health and the situation here in Flint ; but following my customary practice of procrastination and postponement, I neglected from month to month to fulfill my promise, until now at this late date I find that stress of circumstances has, in a very real sense, brought my affairs to a pass nearly re- sembling a crisis so that I feel that I cannot well afford any longer delay in apprising you of the important changes that are impending here in Oak Grove. First let me thank you for consenting to assume charge of the parcel of papers sent to you and acknowledged in your letter. Accumulations of old files of letters, magazines, books, etc., are unavoidable and, pending my demise or de- parture from Michigan it is necessary to put in storage por- tions of those which I am not yet prepared to either destroy or alienate; and let me here say that it is quite likely that I will desire to dispose of another consignment of chattels before the approaching 'denouement' (whatever form it may take) transpires here in Flint. But possibly I may not im- portune you in this instance and may try or some other unfortunate for the next offense of this character; and in any case it is not a matter of transcendental importance how- ever it may be dealt with. Occasionally in your letters to me, you have referred to Dr. Burr as your informant and adviser, as to my state of health and have even hinted at regular bulletins received from him in this behalf : I have always rather smiled at this and wondered what it was that he could improvise that would INSANITY. 183 be really illuminating in the premises ; as I so seldom see him and he is such a very active 'man of affairs,' that it is difficult to believe that he would offer you much of value; however, it is possible that I have misjudged him in this respect, and if you have heard from him at any length dur- ing the summer, it is quite probable that he has informed you of the sale of the Oak Grove properties to The Flint Board of Education,' and the approaching dissolution of the Corporation and the discontinuance of the Sanitarium regime ; yet such is the case : the final decision of the Flint Board in regard to the purchase of Oak Grove was arrived at by a majority vote last April, and it is now only a question of a few short months before I shall have to leave Flint and seek another retreat or place of abode that is to say pro- vided I don't die in the meantime. There is no escaping the inevitable logic and the eventuality of these facts it is now a 'fait accompli' and it doesn't matter whether it will be three months or six months, or nine months before the actual closing up of the hospital the end of my course here is now practically at hand. The "play is played out" in Michigan, and the sooner I get out the better ; and as far as my per- sonal inclinations are concerned I don't mind telling you that I would gladly leave Flint to-morrow if it could be satis- factorily arranged. The truth is that the last ten or twelve months passed in this retreat have been the dreariest and most miserable of my whole career, and whether or not the physicians have troubled themselves to inform you the con- ditions affecting my general health have been what I con- sider very unusual and dangerous; so you see there is nothing to be gained by prolonging my stay in Michigan. It is true that the 'doctors' are still kind and of course com- petent in their ministrations but it is quite natural that they should not have the same interest as formerly ; and there will be other palpable signs of that, neglect or indifference in administration that would in the nature of things be in- cidental to the closing out of the business. And again my friend and neighbor who for fifteen years has occupied the 'suite' adjoining my room Mr. clever and ac- complished 'gentleman' and one of the nicest men I ever met 184 INSANITY. suffered a stroke of 'apoplexy' and after a brief illness 'passed away,' less than a month since not only was his friendship a great solace to me, but as a neighbor the ar- rangement of his room next to mine afforded a minimum of disturbance that was of inestimable value to me. Of course it is not necessary or advisable in a letter to you to go into a minute summing up of my experience here in Oak Grove or to dilate on the merits of the treatment I have received or on the 'general equities' of the whole situation either from the standpoint of the Sanitarium authorities, or the Michigan community at large ; suffice it to observe in passing that I came here voluntarily in good faith on mild solicitation from Dr. Burr and on assurance of safe-conduct and 'honourable treatment.' Hopes of any real benefit or established cure from my course here have long since been abandoned, and although one of the Doctors recently in reply to my expressed desire to wind up my affairs and arrange for an early departure not only en- deavored to assure me that my present dangerous conditions would soon improve and disappear but that he and his col- leagues yet hoped that I would not leave without some palpable benefit such as I was led to believe would accrue to me when I first began my course : Yet I am convinced that his remarks were largely 'professional camouflage' and as has been said of certain German Government announcements during the war "designed chiefly for home consumption." It is my own matured judgment that I have long passed the point where there is any advantage in abiding in Michi- gan and that every day passed here is lost ground. The community which has not in twenty long years done for me what is necessary to establish my position is not likely to do it in twenty-one years, or in twenty years and six months. Certain considerations in my behalf that might have en- listed some little interest at the beginning of my stay here in Flint would be urged with little or no effect at the present juncture. The 'society' here like the city itself, has entirely outgrown its original limitations and from the comparative obscurity of a 'small-town' community of 13000 inhabitants INSANITY. 185 Flint has now grown to be the third city in Michigan in population (the estimates now give it more than 100,000) and is one of the first in importance. As an industrial center, Flint occupies a most conspicuous position and possesses even a National significance; for it is the acknowledged center and one of the chief headquarters of the great motor industry now such a tremendous factor in the business world. The residential society has expanded accordingly and though Flint is fairly crowded with the prettiest girls imaginable girls who dress well drive their own cars and evidently en- joy good 'positions' in the social world with almost unlimited resources of wealth, influence and income, Yet notwith- standing these advantages of surroundings I may say that I have not the slightest knowledge of or interest in anything they may represent and possess absolutely no acquaintances: indeed I have not had an opportunity of meeting or speaking to a single girl in about sixteen years ; although I have reason to believe that other guests in the Sanitarium as well as in- consequential members of the municipal corporation have enjoyed in some way or other some of the advantages of association which the Society offers. Not even in my dreams do I enjoy communion with the human species that coelestial consortium which I understand most everybody participates in my position, therefore, you see is one of complete and 'splendid isolation.' Without wishing to criticise or reflect in any way on the authorities in Oak Grove or the leaders of the Detroit-Flint 'social regime' I believe I am justified in observing that the general attitude of a controlling element of the surrounding population and the treatment I have received at their hands has been what Baillie Nacol Jarvie would describe as "con- siderably on the north side o' friendly" though probably few here would confess to any knowledge of me or my identity; 'and if they were told that I came to Flint of my own accord to "twist the Lyon's (sic) tail" and to save 'my position' and the Yale and Puritan Government they would in all likelihood refuse to understand a syllable of such an appeal. Indeed as far as the broader and political aspects growing out of and leading up to my position are concerned it is 186 INSANITY. inconceivable that many of these people have the remotest conception of what is involved in the propaganda and the general scheme in which they themselves are the unwilling tools and the unconscious, irresponsible agents. I have always elected to consider and conduct myself as a patient and a guest of Dr. Burr and of his constituents and in thus describing the details of my situation here, I am merely endeavoring to throw some light on the factors to be taken into account in securing a transfer to some other community. Dr. Burr accordingly in the final analysis is, or should be, the prime authority to appeal to in securing for me a satisfactory 'get away' I know that in a certain sense my fate depends on the vote of the 'powers that be' and the 'men higher up' " but, among these I consider Dr. Burr and his constituents occupy a place of paramount in- fluence as far as my case is concerned and whether or not they acknowledge a moral responsibility, I am confident that with your acquiescence they could obtain for me a transfer to more favourable surroundings, such as would be agreeable to me; that is they could if they insisted upon it secure a unanimous expression to that end which could be acted upon forthwith as the 'order' of the day. My great fear is that by prolonging my stay unnecessarily in Oak Grove, my condi- tion may change for the worse and that when the final 'round-up' comes there will be an effort to railroad me to a State Institution : I have a horror of such a 'denouement' and frankly would much prefer death to such an eventuality. It must be understood that although the great majority of the people of Michigan are 'noble at heart,' right minded and generous in disposition there is an element, a very strong element that is unfriendly to me, and which has ever acted adversely to my best interests, and which may exert its influence to keep me in bondage and cut short my career by relegating me to 'Pontiac' or some such place in the manner I have described and our good friend, Dr. Burr with all his admirable qualities ("which nobody can deny"), his benignant disposition and stalwart courage might not see his way clear to vetoing such a catastrophe : as he is a thorough "man of the world" and professes no great altru- INSANITY. 187 istic affection for me Indeed he bears a strong resemblance in character, to old 'Louis XI. of France' whom -Sir Walter Scott ap'ostrophies as "a wiley (sic) and insidious politician" with a large alloy of that personal selfishness which men in the 'Seats of the Mighty' so often possess: and he Dr. Burr peradventure would be more likely to make capital for himself by playing into the hands of the aforesaid powerful element (that is inimical to me) rather than to interpose in my behalf that carefully built up 'tower of strength,' the 'prestige' of his individual popularity and in- fluence. I may be narrow and without a good warrant in some of my conclusions but it has always seemed to me that the 'Oak Grove Community' is pre-eminently one that toler- ates 'snap-judgments' that is: a place where hasty decisions on very important matters are continually being made in many instances without any regard to equity, common jus- tice or common sense : and it is always problematical what may happen from one day to the next, and my own fortunes have been blasted and are in danger of being completely ruined by these ill considered, hastily derived verdicts. It is well known to you as also to the authorities here that although I possess no friends in this community and have not succeeded in enlisting the interest, sympathy, or favorable consideration of those immediately about me still there are some very respectable not to say influential ele- ments in other parts of the country that have persistently manifested an active interest in me and my cause, and have endeavored to the extent of their ability to aid me by many marks of recognition and encouragement; the best of Yale, the best of Harvard, and the best of Columbia have done and are still doing what they can to assist me; and my many friends in the East and in the Southland not to mention various factions, nationalities and movements in other parts of the world have given tokens of watchfulness and sym- pathy and altho it is not much that they have been able to do still the measure of their divine patronage is in the will rather than in the deed and I on my part have under- taken as far as possible to justify this Evangelical and altruistic succor by maintaining in thought and deed and 188 INSANITY. writen word an honourable consistency with the standards and ideals which they have held out to me. Would it not be most unjust and unfair to these ultrarespectable allies of mine to relegate me to the degradation and practical oblivion of such an environment as a 'State Institution' thus ending my career forever Indeed such a retrogression would be a positive insult to their kindness and a rebuff to the courtesy of their expectations. Now supposing this unhappy fate which I have outlined as one of the dangerous possibilities can be successfully avoided the question arises what 'retreat' or place of abode, suited to my own inclinations and partialities can be secured for me? It would seem that all the equities if not common decency would demand that my own 'personal wishes and ambition should be heeded and advanced in view of all my sufferings, my long exile and martyrdom, which I took upon myself voluntarily and for the noblest and highest of pur- poses and in view of the inexorable laws of compensation and retribution, that in the final judgment are supposed to assure to human probationers their 'hearts' desire' In this land of liberty, freedom and self-determination why should not mime be the deciding voice in the disposition of mine own person? Conceding then that my own wishes are to be primarily consulted : my first choice for a place of residence would be : New Haven, Connecticut in some quite household that would consent to take me as a guest and patron ; and here let me explain that it is the moral support of a friendly community that is necessary to the maintenance of my existence and not "institutional treatment" of any sort; I mean by this that, in order to keep alive and sustain my general health it is not required that I live in an 'Institution.' There is no community in America more friendly or more competent to give me this moral support than the New Haven background, and no environment better suited to my tastes and to my purpose of pursuing a 'literary career' Moreover, I am the representative of a family. My Father lived in - - for a number of years ; and as you know our 'Yale position' and Yale sympathies amply ex- INSANITY. 189 plain and justify such a preference. In short if I live and am not obliged to go to another retreat I would elect to reside in quiet seclusion in the 'beautiful City of Elms' and as you are well aware, the expense of maintenance under such circumstances would be less than in a private Sanitarium. Passing to the other alternative my removal to another in- stitution, there may not be a very wide field to choose from but it must be in some locality outside of Michigan. I have absolutely no interests in Michigan and am not a citizen of the commonwealth and there is no hospital or retreat in this State that I would ever consent to live in : altho' there are circumstances conceivable (though not very probable of re- alization) under which I might desire, for a time, to reside 'at large' before leaving Flint; that is if I were perfectly well and established in my position, I might be induced to pass a few weeks at a Hotel or 'pension' in this city. Now as to another hospital or sanitarium outside of Michigan there is only one that has even been seriously recommended as an alternative to Oak Grove and that is the one at 'Wau-wa-tosa' near Milwaukee, Wise.; and there are a num- ber of considerations that might incline me to favour such a destination ; as its proximity to Chicago and the strong endorsement given it by many competent to judge. My strongest partialities, however, favour the Eastern and tide- water section of the country where I possess many vital in- terests and associations and it seems incredible that there should not be some similarly suitable place near New York or in Connecticut or Massachusetts. The expense at Mil- waukee would probably be greater than here in Oak Grove but I think it would be quite possible to make such arrange- ment of my property as would enable me to try it there for a while at any rate. If all goes well I should hope and desire to get out of Michigan early this Fall that is by the Fifteenth of October next at the latest. Having thus stated my position and my views in regard to what, to me, is a very important and vital matter I trust you will give it your earnest consideration ; as the final determination is or should be largely in the hands of Dr. Burr and yourself. I am well aware that you have little 190 ' INSANITY. or no personal interest and could justly retort that you are in no way responsible for my fate; and that such aid as you have thus far extended me in the management of my affairs has been entirely gratuitous But in cases of this sort, some one among the next of kin' must of necessity be looked to to assume the office of administrator and I shall in this instance as in the past be most grateful for such assistance as it may be possible to accord me. It is possible that I may not long be a burden to my friends for, as I have hinted these surroundings are dangerous to my health and death may claim me at any time. . In one of your former letters you spoke of recourse to religious devotions and reading of the Bible for solace and inspiration. I have always made a practice of reading at least one chapter in the Bible before retiring each night ; and I'm sure the well-thumbed appearance of portions of my 'Scriptural text-book' will bear witness to the sincerity of my orisons. In conclusion this letter has already reached such volum- inous proportions that I will not attempt to include any dis- course on current events, or observations on the 'political situation' as it bears on the fate of our American Democ- racy. I trust this will find you and your family in good health and prosperity 'Poor old Chicago' I see is as usual contrib- uting her share to the 'general cussedness" of the labor sit- uation and is living quite up to her time-honoured reputation in the way of strikes, race-riots and other forms of politico- industrial deviltry Long may she flourish I am confident she will weather all storms. With kind and affectionate regards for yourself and family I have the honour to be Very sincerely yours Pellagrous Insanity. Never having treated, or at least, never having recognized as such, a case of insanity of pellagrous INSANITY. 191 origin, I am unable to write of the condition from personal experience. Cursory observation, however, of a shockingly large number of cases in a southern hospital, attributed to pellagra, leads to the conclu- sion that the symptomatology is in a relatively early period of the disease, that of mental deterioration. The leading feature of the most recent cases was that of depression: of the advanced cases, brain and nervous decay. There were many whose symptoms vastly resembled paretic dementia in its terminal stage. Diagnosis must, I think, rest mainly upon the skin and other manifestations of the disease and upon die previous history of the case as to diet and en- vironment. Dr. Wm. A. White has kindly contributed the fol- lowing observations: "There has been very little study of the mental symptoms of pellagra of late years. From the few cases I have seen and from talking with those who have had it under observation there seems to be a variety of symptom pictures. "Many cases present no nervous or mental symp- toms at all. In those who do there seems to be a tendency toward a variable localization of the disease process. There seem to be cases in which the spinal cord suffers most and others in which the brain suffers most. In this latter group a condition of very acute delirium may be developed running a rapid course to fatal termination and reminding one of the acute forms of paresis. The more frequent condition, of which I have seen a number of cases, seems to be more in the nature of a simple retardation. The patient moves slowly or not at all, and answers questions 192 INSANITY. after a long delay in a low tone of voice and in monosyllables. There does not go with this retarda- tion, however, an emotional depression as in melan- cholia. I have also seen pellagra phobia in an in- fected territory. "With this disease, as with many others, we must not forget that it may be associated with various psy- choses without having any other relation to them. This is particularly so in this country as the large groups of cases which have occurred have been in hospitals for the insane. "Perhaps Gregor has made the most careful recent clinical study of the mental symptoms, lie con- siders his cases under the following seven categories: (1) Pellagrous neurasthenia, (2) stuporous group, (3) mental aberration, (4) acute delirium, (5) kata- tonia, (6) anxiety psychosis, ' (7) manic-depressive group. It does not seem clear, however, just what is the connection in all of these cases between the pel- lagra and the psychosis." PART IV. MANAGEMENT OF CASES OF INSANITY FROM THE MEDICAL STANDPOINT. IN former times it was not considered a matter for reproach for a physician to admit entire absence of familiarity with so-called mental disease. The state- ment, "I know nothing of insanity," was by no means infrequent this, perhaps, from one appointed by the court to make an examination of the mental condition to determine the necessity for hospital treatment, for the purpose of advising as to an alleged criminal's re- sponsibility, or called to give testimony upon a medico- legal question requiring expert opinion. Now all this is changed. There is a growing interest on the part of the general profession in the subject of mental disease. Medical schools are teaching psychiatry as a special branch. Clinics in insanity are held in various State hospitals, and the ability to differentiate forms of dis- ease becomes part of the graduate's equipment. Psychopathic hospitals for the care of recent cases have been organized in different parts of the country and constitute an aid to the teaching of psychiatry in medi- cal colleges. It would now be looked upon as a confession of fail- ure to say, "This patient is insane," without an attempt at least to classify the case. Just as one called to see a patient with high temperature will aim to discover the reason for its existence, so will the present-day practi- 13 (193) 194 MANAGEMENT OF CASES MEDICAL. tioner intelligently apply diagnostic principles and place the insane case in its proper category. This more seri- ous view will prove of much practical benefit to pa- tients. It will hasten the coming of that time when antiquated and erroneous notions of the nature of insanity will be abandoned, sentimental considerations swept away, and cases of brain perturbation showing disturbed mental action as a manifestation viewed from the same position as are those of pneumonia, gastritis, or typhoid fever. Called to see a patient showing that group of symp- toms to which the collective term "insanity" is applied, the physician is usually confronted with one of three prominent conditions giving character to the case, viz., mental excitement of varying degree, mental depres- sion, or mental weakness. Excitement occurs in manic-depressive insanity, in infection and exhaustion psychoses, in alcoholic or nar- cotic delirium, in paretic dementia, and episodally in epileptic states, in paranoia, and in the various forms of dementia, organic and simple. The physician will usually be able, through inquiry into the antecedent condition, to assign the case to its appropriate group. In general, it may be said that ex- treme agitation, suspiciousness, and painful emotional states accompanying excitement argue the existence of the depressed phase of manic-depressive insanity, and self-satisfaction, mental exaltation, pleasurable emo- tions with flight of ideas and pressure of activity, the excited phase of this form of disease. Excitement with verbigeration, incoherency and auditory hallucinations and depression with katatonic attitudes, stupor, and negativism are strongly suggestive of dementia praecox. MANAGEMENT OF CASES MEDICAL. 195 Paretic dementia is to be feared if, in connection with excitement, there are pupillary changes and muscular inco-ordination, and may be suspected in the absence of these if there have been previous mental confusion, extravagant or erratic conduct, failure in memory, and marked departure from the normal in appreciation of the fitness of things, in domestic rela- tions, and in sense of propriety, extending over a period of weeks or months. The history of the case should be thoroughly sifted, and any well-established or con- tributory cause of nervous breaking down, such as the results of injury or a pathological condition which would, under other circumstances, require surgical measures, should be sought out and removed, but by all means a receptive attitude should be maintained and a broad and comprehensive view taken in determining the etiology. Be the diagnosis what it may, the indications for treatment are clear, the object being to reduce excite- ment and strengthen self-control. The patient should be placed in bed at first and cared for as if physically ill. Years ago it was the custom to give considerable exercise to patients of this class, and the fact should not be ignored that excitement must have vent, and to repress it too much is to do the patient harm ; but of late years there is a growing tendency toward the op- posite course the conservation of strength with just sufficient exercise prescribed to divert, amuse, and furnish change. Almost without exception, cases of mental excite- ment do better in bed, in a quiet room away from dis- turbing influences, and although it is a difficult matter to persuade one in mental elation conscious of ability 196 MANAGEMENT OF CASES MEDICAL. to move mountains and perform feats of great strength that he needs rest, the rest should be given and the vital forces husbanded as carefully as possible. Two judicious, level-headed, quiet, unobtrusive nurses, one for the day, the other for the night, should be provided at once. These should be accustomed to the management of such cases, and preferably gradu- ates of a training school of some hospital for the in- sane. Members of the family should, so far as pos- sible, be excluded from the sick-room. As a rule, their presence is harmful. Powers of self-control exercised by the patient alone with his nurse are often abdicated entirely in the presence of near relatives. In the family there is too often erring on the side of overdoing and fussy attention and in gratifying morbid whims. Various impressions derived from the attitude and manner of solicitous relatives give rise to uncomfort- able sensations in the patient. He recognizes, for example, that his mother is suffering from emotional strain on his account, and if not conscious of being out of health he is amazed perhaps annoyed by it. If so conscious, particularly if suffering from undue anxiety about his condition, the concern of others merely serves to add to his own load, and the delusion that he brings trouble and misfortune upon his family is liberally confirmed. In particular, where delusions are in exist- ence concerning some member of the family, this in- dividual should keep out of the patient's sight. It will do no good to one who believes her husband dead, ill, or unfaithful, to have the unfortunate object of the delusion in constant or frequent attendance in the sick- room. One cannot treat a disturbed condition of brain by demonstration of the falsity of morbid concepts. MANAGEMENT OF CASES MEDICAL. 197 % Better that delusions be ignored or denial of them be made only at long intervals, and positively (without discussion), than to attempt to counteract them by the exercise of logic and argument. In excitement as well as depression there will fre- quently be found a state of autotoxic constipation and imperfect digestion with malassimilation. Indeed, to make a momentary excursion into the realm of prophy- laxis, it is especially important to combat the tendency to constipation so prevalent among the American peo- ple, especially American women. An incredibly large percentage of nervous disease owes its existence to neglect of the bowels. It should be impressed upon patients that grave dangers to health lurk in irregu- larity in this function, and when constipation is in existence, systematic efforts should be made to over- come it through calisthenic exercises, liberal potations of hot water before breakfast, and abdominal massage. We are on vastly better ground for the comprehension and scientific treatment of this condition than ever before, owing to the development of the theory of auto-infection. In constipation attendant upon insane states there is no remedy so good as calomel given in sufficient doses for thorough results. Thereafter the bowels should be kept in a soluble condition by the use of the effervescent salts, aperient waters, fluid laxatives whatever the patient can be induced to take and finds most agreeable, the calomel to be repeated when the coated tongue, foul breath, and general phenomena of impaired action of the stomach and intestinal canal give occasion for its use. A valuable drug for use in this condition is the effervescent phosphate of sodium. 198 MANAGEMENT OF CASES MEDICAL. f I have elsewhere said : J "The theory of autotoxis as a causative factor in the psychoses and neuroses has furnished a working basis for the explanation of cer- tain departures from the normal in the cerebrospinal sphere of activity. That the theory has been over- loaded, possibly goes without saying. This is unfor- tunately true of every illuminating theory, but many pursuing the treatment of nervous and mental maladies are reasonably well assured that deductions from the favorable action of eliminatives post hoc justify the further propter hoc assumption of the causative rela- tion of retained toxins to nervous perturbation. "Constipation is a bane of mankind and seems un- avoidable under present-day conditions of living and work. It is especially the bane of womankind, and is often developed at an early period of life through in- adequate or indecent toilet facilities in the public schools. 'We have taken your advice and built our new school-house around the water-closet,' said an ex- perienced member of a Board of Education to the writer on one occasion. "Constipation is indubitably a factor in, if not the ultimate cause of a frightfully large proportion of mental cases. Its correction and the relief of incidental malassimilation are ends to which the experienced psychiatrist directs early effort. Realizing the impor- tance of elimination, it is impossible to refrain from a congratulatory expression to the author of this book for his painstaking directions for the medical relief of intestinal torpor. Symptomatically the nervous case is 1 Under the heading "Psychopathic Nephroenteroptic Symptomatology," in the book of Dr. H. W. Longyear, of Detroit, on "Nephrocoloptosis." MANAGEMENT OF CASES MEDICAL. 199 invariably improved by skilful attention to abdominal conditions arising from constipation. Is your mental patient restless attend to the bowels. Is he irritable- attend to the bowels. Acquaint yourself with the con- dition of the teeth, the ears, the eyes, the chest organs, the kidneys but incidentally unload the bowels. Is he sleepless see that the bowels are active. Is he lacking appetite empty the bowels. In the experience of the writer the best hypnotic is often a dose of castor oil, and the best tonic a colon flushing. Elimination and again elimination toujours elimination should be the watchword in the treatment of morbid mental states. "It is probable that fecal impaction of large amount is a more frequent condition than is generally recog- nized. Experience in many cases one very recent indicates that impaction may be present in extreme degree without obvious abdominal indications pointing to colonic distention. Nurses may be deceived by the appearance of regularity in patients' stools, while emptying the intestinal canal at higher levels than the sigmoid does not occur. When through well-directed effort this finally takes place the amount of fecal ac- cumulation may be astounding. "That perverted emotional states in relatively healthy individuals may be induced by temporary bowel in- activity needs no demonstration to one habitually regular in this function. Prevented from its perform- ance, there are irritability, hebetude, lassitude, malaise, vasomotor perturbation: the person's mental output is indifferent and his emotional responsiveness is un- stable. Add to the sensations thus induced the results of months or years of habitual constipation, and it is 200 MANAGEMENT OF CASES MEDICAL. not difficult to understand how morbid habits of think- ing may be augmented, if not engendered, by chronic bowel torpor." Further experience emphasizes the importance of the principles laid down in the above declaration. No remedies have so important bearing upon the treatment of 'morbid mental conditions as those of this class. Many a patient is relieved from profound depression through the daily laxative or enema or both. Many an outbreak of excitement is modified or averted by active purgation. Constant vigilance to meet the con- dition of constipation is necessary. As to the particular laxative, it matters .less than that one which is efficient shall be administered. My preference is for the salines (Abilena Water, Epsom or Rochelle salts, Seidlitz powders, effervescing citrate of magnesium) before breakfast, castor oil at night or at any convenient time during the day, calomel in the large single dose of 3 grains and followed by a saline; lastly, the compound cathartic and the improved compound cathartic pill of the Pharmacopoeia. It cannot be said of cathartics, as some evilly inspired person has said of whisky, that some kinds are better than others, but that all are good. Cascara is, in my opinion, practically valueless. It is not adapted to those states of visceral torpor prev- alent in mental diseases. Supplied with it week after week, a tolerance is established. It is perhaps the most readily accepted of any of the pharmaceutical prepara- tions of a laxative character this because of the nice- ties developed in its manufacture and the agreeable character of the preparations which the pharmaceutists have put out. The remedy petrolatum, given as advised by Long- MANAGEMENT OF CASES MEDICAL. 201 year, has been found serviceable in certain neurasthenic states. I quote: 1 "For this purpose the author has found nothing else which serves the purpose as satis- factorily in most cases as the so-called 'petrolatum oil,' or liquid vaselin. The properly prepared oil should be tasteless,, nearly clear not amber colored and should be thick and heavy in consistency. The thin oil, which is used largely as a medium in spray medication, is not suitable for this purpose. The preparation is chemically paraffin, and not a fat, as its name would signify, and consequently does not saponify with alka- lies, or become digested or altered in passing through the alimentary tract. It is this quality which causes it to act in a mechanical way only, passing through the stomach and small intestines unchanged, and then into the colon, where, by mixing with fecal matter and coat- ing the mucous membrane, the effectiveness of peri- stalsis is augmented; the contents of the bowel pass over the angulations with a minimum amount of effort and irritation, to the subsequent comfort of the patient. The dose is usually one tablespoonful taken clear twice daily on an empty stomach. The author usually directs one dose to be taken late in the afternoon, about an hour before the evening meal, and the other at bedtime. The effect of this oil is usually sufficient to cause the contents of the bowel to pass into the de- scending colon and in some cases to result in regular and satisfactory defecation." It is quite evident that certain principles of treatment which are considered important in hospitals are diffi- cult of application elsewhere, and what to do for the 1 "Nephrocoloptosis," C. V. Mosby Company. 202 MANAGEMENT OF CASES MEDICAL. insane in private care often presents itself as a perplex- ing problem. Surrounded by anxious friends and curi- ous neighbors, the patient noisy, the house in commo- tion, and the circumstances such as to call forth irresponsible comment, criticism, or censure, it is diffi- cult for the physician to remain indifferent to the clamor for medicine to produce quiet. It can be said, however, positively and without qualification, that remedies directed to subduing the patient, depressing drugs, hyoscyamine, conium, tartar emetic (recom- mended in a textbook, but I fancy seldom, if ever, employed), the bromides, do no permanent good and are often productive of harm. The quiet they bring about is at the expense of strength. It should not be forgotten that, however much strength may be jnani- fested in excitement, this is largely fictitious. To re- strain muscular activity by the use of drugs is not curative. There is brain exhaustion to deal with and the rapid combustion of nervous tissues must be met by sustaining remedies and those which promote nutri- tion rather than by those which lower the heart's action or act directly as paralyzers of muscular activity. In the daytime, therefore, it should rarely be attempted to produce sleep by the use of drugs. Natural sleep that which comes spontaneously or follows a hot bath, a glass of malted milk, or a salt glow and massage should be favored at all times, whether day or night, but hypnotic drugs should be avoided if they can pos- sibly be dispensed with, and should be used, when necessary, only at night. As a pure sleep producer, I know of no drug equal to chloral hydrate, and singularly, although all my life I have heard of the chloral habit and of chloral dependence, I have never MANAGEMENT OF CASES MEDICAL. 203 encountered a case of it. I have never known its use to create a craving, or its withdrawal, when the nerv- ous system was restored to the point to permit it, to be followed by sleeplessness attributable to the with- drawal. Its use is open to objection where there is feebleness of the heart, but even in such cases where this is not extreme, its effects are happy, and cardiac depression can frequently be counteracted by the use of quinine. A 15- or 20- grain dose of chloral hydrate is as large as it is well to prescribe. Sometimes to this a few minims of fluidextract of hyoscyamus or a tea- spoonful of elixir valerianate of ammonia may be added; or the bromidia may be substituted. Usually there should be no occasion, if the patient has been sufficiently and properly fed and cared for during the day, to repeat the dose more than once three or four hours after the exhibition of the first. When sleep fails to appear after this medication, resort to other means is preferable to repetition of the dose. Kraepelin speaks of death following a 5-gram dose of chloral hydrate. This is quite probable. How- ever, never having 'given to the same patient more than 60 grains in divided doses (and this in rare instances) in one night, I am unprepared to confirm from personal experience an expression concerning a lethal dose. The use of chloral in the epileptiform seizures of paretic dementia, with the exceptional case in which untoward results were obtained, and the abuse of chloral giving in alcoholism, have been discussed under these heads, respectively. In status epilepticus it is useful given by rectum in conjunction with the bromides. Paraldehyde is an all-round, frequently available, and practically danger-free drug. Under 1 or 2 drams, re- 204 MANAGEMENT OF CASES MEDICAL. peated in two hours if necessary, quiet, restful sleep is apt to occur. It is objectionable to the palate, but its remote effects are happy and the warmth and glow following ingestion so immediate and constant that the danger of establishing dependence upon it should be borne in mind. The drug has a wide range of utility. Sulfonal, veronal, and trional are also excellent sleep-producers, and in some cases supply a want that chloral does not meet. In neurasthenic states and in the agitated forms of manic-depressive insanity they are especially useful. Their good effect wears out, however, and they are not well suited to nightly ad- ministration for any length of time. They are best given in hot milk, and if merely the suggestion of a hypnotic is required, beta-naphthol may be substituted. In a hitherto-reported case of morphine addiction in which there was undoubtedly some idiosyncrasy, the prolonged somnolence following a moderate dose of sulfonal mitigated very materially the discomforts at- tendant upon the withdrawal of the accustomed nar- cotic. It is especially true of sulfonal that the "hold- over" effects are considerable and dullness occurs on the day following its administration, which interferes materially with the psychomotor output. However, in connection therewith the measure of emotional blunting may contribute to the patient's comfort temporarily. There are cases rare indeed that demand and are benefited by an occasional dose of morphine, codeine, or some extractive of opium. It goes without saying that the administration of any of these medicines should be extremely infrequent, both because of the danger of habit-forming and the increase in bowel MANAGEMENT OF CASES MEDICAL. 205 torpor, their inevitable accompaniment. The cases benefited are those of acute agitation, frenzy, where there is great distress and where painful delusions lead to the refusal of food and to suicidal acts, and forbid sleep. The remedies kola, coca, strychnine, quinine, capsicum, valerianate of ammonia, dogwood, are all of value in the treatment of habit cases and are else- where discussed. In exhaustive states attended with flushed face, muttering, shifting hallucinatory impres- sions, furred tongue, sordes on the teeth, faucial dry- ness, in short, a typhoid condition sine typhoid, the use of strychnine hypodermically, and the normal salt solution and quinine by the rectum, is most desirable. Coincident with their employment there frequently ap- pear improvement in the pulse, temperature reduction, increased flow of urine, and willingness to accept nourishment. These remedies in connection with care- fully managed hydrotherapy topical cool sponging, cold applications to the head bring relief to conditions which occasion great anxiety. Chloretone in 3- to 5- grain doses may be given to relieve painful conditions, particularly those proceed- ing from the abdomen. As a sedative pure and simple there is now and then indication for hyoscine hypodermically. For the com- fort of the patient and the repose of the household its use may be unescapable. It must be rare, however, that necessity shall arise for its administration. Fortu- nately, there are hydrotherapeutic measures in vogue in recent years that quite fully take the place of that "chemical restraint" much denounced by reformers of a few decades ago who felt called upon to voice their opposition to it in tones implying that they alone were 206 MANAGEMENT OF CASES MEDICAL. righteous and their neighbors not half as good as they should be. It is perhaps sufficient to say that in this day and age the potential prescriber of a sedative designed to modify excitement and bring about tempo- rary motor inadequacy will think twice and perhaps again before resorting to the convenient little tabjet and hypodermic syringe and will direct that his patient be given a prolonged bath of hours' duration in water at a uniform temperature of 100 F. It is more than likely that in most well-ordered hospitals for the insane at the present time the supply in hand of hyoscine tab- lets has undergone a degree of deterioration through age that noticeably interferes with their solubility. In advocating bed treatment of recent cases, I would not be understood as being opposed to giving such cases as are physically able to bear it a moderate degree of exercise in the open air. If, however, confusion and excitement are not relieved, or are increased by exer- cise, it should be omitted. Tonics and remedies to promote tissue building are needed. The bitter tonics and strychnine, capsicum and nux vomica, iron preparations, the mineral acids, the hypophosphites, malt preparations, all are valuable in selected cases. Eggnog and milk punch, containing from Y-Z to 1 ounce of whisky, will be needed occa- sionally, and whisky or brandy in small and frequently repeated doses is valuable in exhaustive states. A good indication for the withdrawal of alcohol is dis- turbance of the vasomotor system indicated by flushing of the face soon after its administration. Quinine is an indispensable agent in exhaustive states, and may be given in 2- or 3- grain doses per mouth or lower bowel from time to time, according" to circumstances. MANAGEMENT OF CASES MEDICAL. 207 The exhibition of thyroid-gland extract, desiccated (P. D. & Co.), was followed by distinct betterment in a case of dementia prsecox of the katatonic type. Coincident with the acquirement of much flesh there were in this case, dullness, irritability, and episodal out- breaks of violence. On occasions as much as 10 grains t. i. d. were given. This resulted in rather rapid loss of weight. Five grains, on the contrary, did not seriously interfere with nutrition and promoted composure and emotional stability. It is desirable to discontinue from time to time the giving of this remedy, resuming its administration after intervals of one or two weeks. If restlessness, excitement, suspiciousness, or irrita- bility are such as to generally demand more than the manual restraint of one person, it will in all probability be the better plan to place the patient in some hospital for the care of the insane. Indeed, in the vast majority of cases of mental excitement patients do better in hospitals than at home. At home the environment is that to which the patient has been accustomed and with which delusions are associated. Again, it is extremely difficult for the physician to secure obedience to pre- scribed regulations, owing to the injudicious inter- ference of anxious relatives ; and still, again, that ideal nurse who shall be familiar with the care of the insane, tactful, considerate, and attentive, who will leave noth- ing undone or unspoken which will be productive of good, but who will omit that which is irritating to the patient, is not always obtainable on short notice. In hospitals he is numbered by scores, and it goes without saying that his services are retained if possible. There are cases of acute psychoses attended by delirium which should never be removed from home, and in the deci- 208 MANAGEMENT OF CASES MEDICAL. sion of the question of removal the physician will often require to exercise a wise and discriminating judg- ment; but it must at least be better, as a rule, in case means of control at home are insufficient without re- sorting to mechanical restraint, to pl^ce the patient where the surroundings savor of sustaining discipline, and where the influence of superior numbers is before him constantly. The quality of mental depression which is encoun- tered by the examiner in his investigation of a case presented may be at once suggestive of the form of disease and an aid to early diagnosis. Depression with self-centering, misgivings, doubts as to the expediency of any plan suggested or effort put forth with hope- lessness and self-disparagement occurring in the in- volutional period of life and attended with visceral illusions points to presenile melancholia. Depression with negativism, torpor, mutism, kata- tonic manifestations and depression, with emotional states suddenly shifting to those of elation, suggests dementia praecox. Depression with pupillary abnormalities points strongly to paretic dementia. The manic-depressive depression is accompanied by impressions of extreme unworthiness, of sinfulness and the fear of punishment here and hereafter. The suici- dal impulse is strong. The leading characteristics of the depression of paranoia are suspiciousness and persecutory delusions. The treatment of mental depression does not differ widely from that laid down already. In depression much better opportunity is afforded for satisfactory attention to any local disorder, for the use of high MANAGEMENT OF CASES MEDICAL. 209 enemata, the employment of massage, and the bestowal of valuable nursing attention, than in excitement, but treatment is much the same in the two conditions. In depression, however, there will be greater need for the use of remedies directed to improving the circulation and stimulating peristalsis. Certain drugs, like kola, coca, and caffeine, are useful also in painful emotional states. I have never had much success in the employ- ment of cannabis indica, and for obvious reasons rarely prescribe any of the alkaloids of opium. They are, however, of distinct service in exceptional cases, as has been already indicated. The static electrical breeze is of great value, given just before bedtime, for its sooth- ing and hypnotic quality. I am no friend of the bromides in the treatment of depression and rarely advise their use in other than the epileptic and epileptiform states. For the neurasthenic headache a simple prescription of elixir of valerianate of ammonia and aromatic spirit of ammonia is often useful. For the daily tonic prescription and for the night hypnotic "that remedy you call placebo" will be found in the end most frequently advantageous to both sufferers the one who receives and the one who pre- scribes. In the frequent cases of depression where a heart tonic is needed I have found the combination cereus grandiflorus, niv; tinct. digitalis, nij ; citrate of caf- feine, gr. j, of which a tablet is manufactured by most of the high-class pharmaceutists, exceedingly valuable. The salt glow alluded to heretofore is beneficial in promoting elimination and improving general nutrition. After a thorough perspiration is induced, as in the Russian bath, fine salt is rubbed on the body and a 14 210 MANAGEMENT OF CASES MEDICAL. cold shower follows. In addition to this, electro-mas- sage administered by the usual methods is often beneficial. When the patient will permit the attention without undue excitement, and there are indications for their use, high enemata may be resorted to every other day to insure the perfect emptying of the large intestine. Indeed, a simple enema will usually be required early in the case, and from time to time later, with or with- out the patient's co-operation. Faecal impaction is by no means an infrequent condition, and immediate im- provement and increase of comfort may come through relieving it. Enemata should be composed of soap- suds, to which may be added turpentine, oil, or glyc- erin, as indicated. Sufficient help should be present to prevent the patient from struggling and to insure against injury. This point is emphasized because of a painful, and in its results fatal, accident which I once knew to attend the administration of an enema. Either in consequence of a fistulous opening at the anus, or of a friable condition of the rectal walls, an enema was once in my experience, many years ago, introduced into the cellular tissue about the rectum. The assistance of vision in enema-giving may be imperatively necessary. The temperature of the liquid must be taken by the thermometer, and every precaution adopted to protect the patient from injury. The heavy oil of petrolatum, of which a tablespoon- ful may be given in orange juice night and morning, is an excellent remedy in obstinate constipation. The normal salt solution in amounts from 6 to 8 ounces every four hours, by the bowel, is of great service in relieving faecal impaction. MANAGEMENT OF CASES MEDICAL. 211 It is no less important that the function of the kid- neys and bladder be looked into daily, and the catheter passed when urination is tardy or insufficient. Patients who are inattentive frequently permit the bladder to become distended, rendering it exceedingly liable to rupture. In mental excitement good may be accomplished in many cases by the application of the ice-cap to the head, or the head and spine, and the hot-water bag to the feet. This treatment is especially valuable in those acute exhaustive cases showing dry mouth, flushed face, rapid pulse, and elevation of temperature. In connection with these applications, strychnine hypo- dermically is indicated. This treatment, conjoined with the use of general tonics and judicious feeding, is often found efficacious even in highly unpromising cases. My experience with the use of the cold pack has been limited. In certain cases of paretic excitement its employment has been of distinct service. In the use of cold water otherwise I have had a varied and satis- factory experience. In sthenic maniacal states the hot bath, with cold affusions to the head and subsequent cool sponging, or the cool sponging alone, are grateful to the patient and of direct curative value. Prolonged baths in water of a temperature not to exceed 100 F. furnish one of the most important of modern methods in the allaying of excitement in sthenic manic-depressive and dementia prsecox cases. They have been recommended also in paretic excite- ment, but my experience with their use in this form of disease has been unsatisfactory. The patient's body should be anointed with vaselin before he is placed in 212 MANAGEMENT OF CASES MEDICAL. the bath. No restraint should be exercised. Permit the patient to move about, to sit up, or recline in the bath, and to splash water at will. He will ordinarily become quiet before long and will display the good effect of the treatment. The bath may be of many hours indeed for days continuously but I am per- sonally in favor of limiting its duration as a rule to three or four hours. Meals and lunches may be given while the patient is in the water. It goes with- out saying that the presence of a nurse in the room to prevent scalding, suicide, or other accident is in- dispensable. In recent years greater thought and attention are being given by physicians to the non-medicinal side of treatment and mental therapeutics has assumed an im- portance unknown to the student of a generation ago. To speak of psychotherapy as a "discovery" is to mis- represent. It can by no means justly be proclaimed as such, but it is nevertheless true that physicians are now putting in practice voluntarily and to a greater extent powers employed unconsciously and to a more limited degree from the beginnings of the therapeutic art. Every uplifting suggestion, every hopeful prognostica- tion, the gentle touch, the soothing word all these are psychotherapeutic and as such their importance is not to be ignored. The power of the old-time family phy- sician lay not alone in his ability to employ drugs and in his surgical resourcefulness, but also in rugged faith, spirituality, and a dominating personality. His expres- sions carried conviction, and in an age not so strongly materialistic his Christian profession and practice gave infusion of hope and strength and confidence to his patient. One branch of psychotherapeutics psycho- MANAGEMENT OF CASES MEDICAL. 213 analysis has been mentioned in the discussion of hysteria. To cases of this group and to hysteroidal complications in other cases its methods may be ap- plied and often with pronounced advantage. The surgical care of patients suffering from insanity should not be neglected or omitted, and any focus of irritation, whether it be a carious tooth, an aching corn, an ingrowing toe-nail, a boil, or an abdominal tumor, should if practicable be removed. Where it is pos- sible to correct a malposition of some internal organ which interferes with nutrition or makes injurious pressure, this should be done. I have elsewhere written 1 as follows: "It follows logically that any structural impediment to peristalsis should, if possible, be relieved and that if relieved, the symptoms dependent upon it will improve. Mechanical difficulties (obstructions) that surgery can reach should be relegated to the hands of the operator. The writer has no interest in that conception of sur- gery which constitutes it the be-all and end-all in treat- ment. Patients subjected to ill-advised operation are rendered worse instead of better. The efficient and helpful surgeon to nervous and mental cases must needs repress the enthusiasm for operating and intelli- gently apply common-sense principles in their care and medication. Many cases recover after surgery when the operation is but an episode. A morbid condition has been relieved, a focus of irritation removed, and the patient is afforded a benefaction comparable with that furnished by a dentist who extracts an aching tooth. In addition, the nursing attention, the pro- 1 "Nephrocoloptosis," Longyear, page 57. 214 MANAGEMENT OF CASES MEDICAL. longed quiet, the rest in bed are all adjuvants to his betterment. "Again, mental and nervous cases recover where obvious and palpable lesions, as of the pelvic floor and uterus, are left uncorrected. The writer has been amazed at the facility with which theoretically pure surgical cases from time to time recover without sur- gery; on the other hand, he has observed the benefi- cent results of surgical attention again and again in mental cases. Rectification of the position of a dis- placed kidney has been contributory to the relief of morbid depression in a case upon which Dr. Longyear operated and in which he and the writer were jointly interested. "The pathological connection between kidney dis- placement and morbid mentality has been heretofore difficult of establishment. That the downward dislo- cation is due, according to the ingenious observations of Dr. Longyear, to a dragging on the nephrocolic ligament the primary fault being one of displacement of alimentary and emunctory organs, with consequent embarrassment to their functioning sheds a flood of light on the subject. The question resolves itself into one of impaired nutrition and autotoxis, and the sequence of events in their etiological bearing upon morbid processes in the nervous system is made as plain as a pikestaff. He who runs may read their significance." Mechanical feeding should be employed if refusal of food is absolute or there is threatened exhaustion from taking too small amounts. Feeding is best ac- complished by the use of a funnel and rubber tube tipped by a syringe nozzle bearing a No. 10 or 12 MANAGEMENT OF CASES MEDICAL. 215 catheter. The patient should be in the sitting or semi- reclining position, the head bent slightly forward. Sufficient help should be in attendance to prevent suc- cessful struggling. One or other nostril will usually be found patulous and into it the catheter should be passed slowly, care being used at the entrance of the oesophagus that the tube does not slip forward into the larynx. If possible, a timely act of swallowing on the part of the patient should be availed of to push the tip of the catheter into the oesophagus from the posterior pharynx, where it has been permitted to remain during the efforts of the patient to dislodge it by coughing and retching. The tube should be immediately withdrawn if strident or metallic cough, strangling or cyanosis appear, and an effort should be made to induce the patient to speak before the next step in the feeding process is taken. Spasmodic action, resistance, and ef- forts at regurgitation having mainly ceased, the food mixture of milk, broth, eggs, or thin gruel is given slowly. The quantity may be small or considerable, in proportion to the digestive capacity of the patient and the amount retained. In exceptional cases of persist- ent regurgitation it is desirable to introduce but a very small quantity at one feeding. Every hospital man of large experience has met with serious some with fatal accidents attending mechanical feeding. Hence the detail which has been employed in describ- ing this usually simple and painless though distasteful operation. OTHEMATOMA. A not rare occurrence among the insane is the development of othematoma, "the insane ear." This is a swelling due to effusion of blood in the substance of the ear between the cartilage and its in- 216 MANAGEMENT OF CASES MEDICAL. vesting membrane. It is usually due to violence, and not infrequently develops from fistic encounters. The following laconic sentiment regarding it, voiced by one having large experience in the care of the insane, is perhaps secretly echoed in the hearts of many others. "You all know the history of othematoma. 'The in- sane ear' used to be a frequent condition. In my ex- perience it has become rare. Only once, on my return from vacation, I found in one ward an epidemic which had attacked seven ears. It was easy to obtain the pathological explanation of the epidemic ; one pugilistic attendant and the prompt imitation of the method among a few patients were the cause, and its work was easily stopped." Time was when I believed trauma essential to the development of othematoma. For more than two de- cades after entering hospital work I saw few 1 cases in which there failed the history of injury, from without or self-inflicted, or some form of accident; and in those cases not directly traceable to trauma, I think I usually suspected it. At the end of that time, however, I was consulted by a prominent manufacturer, leading a strenuous business life, but not exposed to any special danger. He had othematoma. The case re- covered without deformity. It was in a way a relief that I failed to find, after the most painstaking investi- gation, the history of any injury whatsoever. I made all sorts of inquiries and suggestions as to how he might have bruised his ear, but he was sure he had not done so. Eventually the conclusion was necessi- tated that, in one case at least, an othematoma not due to trauma had occurred. An interesting fact in this connection is, that several years before this man had MANAGEMENT OF CASES MEDICAL. 217 suffered from an attack of mental depression. He fully recovered, however, in due time. If the hematoma is small and the swelling not very tense, it may be left to subside. The best results which I have ever seen in a case, however, followed the evacuation of the contents of the sac and the applica- tion of pressure. On the subsidence of the swelling there is apt to be contraction of the ear and great dis- figurement. The care of the recent case during convalescence is a delicate and important matter. Access of friends and relatives to the patient should not be permitted prematurely. Effort should be directed through mas- sage, hydrotherapy, electrotherapy, calisthenic exer- cises, and light physical employment adapted to his capacity, to build up the strength and promote cere- bral nutrition. Let the patient vegetate mentally. Cerebral effort should never be actively stimulated, and any attempts to draw the patient out, to jolly him, to excite his interest in conversation, are apt to be con- fusing and provocative of relapse. The physician must safeguard such patients with the utmost care. It will be well to hesitate long before advising change of scene and travel for neurasthenic and de- pres~ed patients. This advice is frequently given and often with injurious effect. Such patients do not bear well the introduction of new and varied percepts into consciousness, but are fatigued and bewildered by it. Their lack of self-confidence is increased by unsuccess- ful efforts to meet changing conditions. Travel may be suited to some cases, but I am persuaded that it has an extremely narrow range of utility. The custodial care of an insane person in a sani- 218 MANAGEMENT OF CASES MEDICAL. tarium or hospital may be necessary or expedient. It may be necessary (1) to protect the patient from himself; (2) to protect others from the patient. It may be expedient when not necessary. Treatment away from home, or in an institution, often accomplishes much for the patient: this for a number of reasons. In the first place, one is apt to exercise greater self-restraint among strangers or ac- quaintances than among relatives. Latent powers in this direction often become active after the transfer of the patient from home. He falls readily into the discipline and regime of an institution, and spontane- ously displays powers of self-control not before appar- ent. The withdrawal from scenes with which former delusions have been associated contributes to this. Regular modes of life prescribed by others take the place of self-appointed rules of conduct. The routine itself is favorable there is less to stimulate, less to annoy. In a hospital the patient laboring under excite- ment is not, as too often happens to one in the care of relatives, threatened or punished for disorderly con- duct. If depressed he is not adjured by everyone he meets to "brace up." In a hospital he becomes less introspective. He is thrown into the society of those similarly afflicted, and finds that his trouble is not more deep and abiding than that of his neighbor. He per- haps recognizes in his neighbor a deluded condition and can criticise in him the conduct which springs from morbid ideas. Each may be suffering from the same general class of delusions, and x each recognize the error of judgment in the other. Removal from home is often an advantage through substituting a real trouble for a fancied one. At home MANAGEMENT OF CASES MEDICAL. 219 the mind is occupied by morbid ideas to the exclusion of everything else. Apart from familiar scenes home- sickness perhaps develops. As two subjects cannot occupy consciousness perfectly at the same time, there is here substituted a healthy for an unnatural feeling, and a motive to recovery is supplied. It is often expedient to withdraw the patient from his family this in consequence of the influence of his conduct upon the minds of his growing children. The example of an insane member of a household, and the anxiety and worry attendant upon his care, are often to the last degree harmful, and tend to the mental de- terioration of others. It may be expedient to withdraw one from the mar- ital relation. There is, in some forms of insanity, marked sexual excitement, and indulgences growing out of this condition may prove a serious obstacle to the patient's recovery. An insane person's removal from home may be ex- pedient for the benefit of society. While not actively dangerous, he may become so under provocation or through the development of new delusions. Though apparently harmless, if he is disposed to wander about and indulge in eccentricities of conduct and conversa- tion he becomes an annoyance, and his presence is de- moralizing to the community. PART V. MANAGEMENT OF CASES OF INSANITY FROM THE NURSING STANDPOINT. THE successful management of cases of insanity necessitates recognition of the physical basis of mental disease, and the direction of treatment to the brain, the organ of the mind. It is the duty of those having the grave responsibility of caring for the insane intrusted to them to have in mind these two great aims: 1. To promote the recovery of patients. 2. To limit the amount of dementia in unrecovered cases, and thereby increase their well-being and happi- ness. As every case of mental disease is a law unto itself, so must each be individualized and treated upon its own merits. There can be no wholesale plan of man- agement. Quickness of perception, kindness, tact, and good judgment are qualities indispensable to the success of an attendant of nurse upon the insane. Kindness im- plies thoughtfulness, attentiveness, conscientious devo- tion: sentiments which find their reflex in judicious, well-directed effort. Coddling, demonstrativeness, and display of warmth of affection are always unnecessary and frequently detrimental to the interest of patients. Kindness should find its chief expression in good deeds, not in words. (220) MANAGEMENT OF CASES NURSING. 221 In enumerating the desirable qualities of a nurse, I would emphasize the importance of one the sense of humor. Years of experience with those in attendance upon the insane has firmly fixed in mind the belief that the nurse who sees the amusing side, who notes her patients' whimsies and departures from conventional standards of acting and expression and derives amuse- ment from them is practically safe and dependable so far as intentional or even impulsive unkindness is concerned. If the nurse enjoys her patient, she will do her best possible in the patient's care and, the deeper the nurse's penetration into the patient's moods, springs of action and habits of thinking, the closer will be the rapport between the two individuals. The sense of humor is a saving grace in many a complicated situation. The recovery of patients is promoted by 1. Building up the general health; 2. Correcting pernicious habits; and 3. Checking morbid impulses. To build up the general health, there are necessary good food, exercise, abundance of sleep, and possibly medication. The ADMINISTRATION OF FOOD is the most impor- tant duty of the nurse, and upon its successful accom- plishment everything depends. Food should be deli- cately prepared, temptingly served, and presented to the patient in an inviting manner. Dishes and utensils should be scrupulously clean and bright ; the tray cov- ered with a clean spread; a napkin provided for the patient's use, which, in case he is fed by the hand of another, should be placed about his neck to protect the clothing. Before giving food, the person of the patient 222 MANAGEMENT OF CASES NURSING. should be cleansed, the face sponged, and hands thor- oughly cleaned by the use of the nail-brush; the nails trimmed. The patient should have an opportunity to rinse his mouth with cold water, and a tooth-brush or a cloth should be used upon the teeth to remove un- wholesome accumulations. Where food is refused from inattentiveness, as in mental excitement, it is often impossible to give more than a few spoonfuls of liquid at a time. In such cases the administration of nourishment should be repeated every hour or every half-hour, as may be, those times being selected during which the patient's attention can be gained when it is the least occupied with other matters. Inattentive patients sometimes take food bet- ter at night, when all is still, than in the daytime. Where food is persistently refused because of delu- sions as in the depressed phase of manic-depressive insanity a careful study of the patient's charac- teristics and peculiarities will commonly point a way to the end, and resort to rectal alimentation or me- chanical feeding will become more and more rare as experience increases. Milk is an ideal food for the insane, and in debilitated cases it is often well to give it in connection with egg and liquor, as in an eggnog. In meeting capricious and delicate appetites, gruels, custards, broths, wine- whey, beef-tea, koumyss, jellies, and fruits will all be found of service. In states of acute exhaustion or threatening exhaustion attended by unhealthy conditions of the mouth and digestive tract, lemon-juice or lemonade in small quantities is often of the greatest value. Certain patients will take liquid food in small quantities where solid food is al- together refused. A patient having delusions of poison MANAGEMENT OF CASES NURSING. 223 may accept eggs boiled in the shell, or potatoes baked in the skins, particularly if the cooking goes on in his presence, naturally believing that no poison can be in- troduced into these articles. One who ignores the re- quest of his nurse or physician may eat in obedience to that of some fellow-patient. Another will take food from the dining-room after the others have left, pick- ing up something here and there, who is unwilling to eat in the presence of others, or who believes that he is unworthy to be served until they have finished. One will eat if left alone and apparently unnoticed. An- other will take food if he can acquire it surreptitiously, and opportunity should be afforded suspicious patients to thus appropriate it. One will eat crackers or bread, or fruit, if placed in his pocket. Another will ex- change plates with a neighbor, and take the food pre- pared for him, believing that no poison has been intro- duced into that particular plateful. One suffering from active delusions of poison may accept part of a glass of milk if his nurse shows sufficient confidence in it to drink a portion in the patient's presence. One believing it wicked for her to eat, will often take food if it is forcibly placed in the mouth the least show of force being all that is necessary to effect the entrance of the spoon. Under this coercion she feels that she escapes responsibility for the doing of that which her conscience disapproves. In giving food, as well as be- stowing other attentions upon suspicious patients, an affectation of indifference is often very efficacious. Under these circumstances a patient believes that the nurse has no personal interest, has no ends to serve. Whatever delusions or morbid impressions influence the patient, whether of repugnance to food or delu- 224 MANAGEMENT OF CASES NURSING. sions of suspicion or poison or extravagance (which latter cause the patient to believe that he is of finer fiber than those about him and not dependent as they upon nutritive substances), the careful nurse will, as a rule, be equal to the occasion, and the necessity for forced feeding will be avoided. There is a wide variety of liquid food of unquestioned value from which to make selection; among these milk, malted milk, Mellin's food, broths of various kinds, and Phillips's digestible cocoa are convenient for adminis- tration and adapted to weak digestions. Mechanical feeding should be the last resort, and the operation invariably be performed by the physician. It should be borne in mind in this connection that there is oftentimes danger of overfeeding; that where a condition of much debility exists, harm may be done by the introduction into the stomach at one time of what would be, under ordinary conditions, a proper amount of food ; the assimilative powers are arrested, the secretions deranged, and the organs of digestion in no condition to care for it. For the purposes of nutri- tion in these cases to give a teaspoonful to a table- spoonful of milk in the natural way after intervals of an hour is better than to administer a larger amount artificially. Milk, preparations of beef, milk-toast, and other albuminous foods may be peptonized or pan- creatinized artificially digested before administer- ing, and in certain instances a purely liquid food may be advantageously given by the rectum, 1 The exhibition of the stomach tube will sometimes 1 In certain cases this is helpful for its moral effect. I have known patients to take food with avidity to escape what they regarded the humiliation of rectal feeding. MANAGEMENT OF CASES NURSING. 225 be -sufficient to induce the patient to take food. The following incident occurred in a Mississippi asylum. Tobe, a depressed patient, decided to end his trouble by starving himself and refused to eat for a week. After trying in vain to induce him to take food, the doctor called for the stomach tube and was preparing to feed him when the following conversation took place: Tobe "Doctor, what is that thing you got there?" Doctor "A stomach tube." Tobe "What are you going to do with it?" Doctor "Feed you." Tobe "How?" Doctor "By putting it down your throat and pumping in milk." Tobe "Doctor, that thing will hurt me." Doctor "Yes, Tobe; but we can't afford to let you starve and must feed you." Tobe (to nurse who was holding a plate of food) "Gimme that plate, I ain't no fool ; I know when to eat." In the ADMINISTRATION OF MEDICINE only the smallest amount of force in opening the mouth is justi- fiable. It is far better, under ordinary circumstances, to give medicine by enema than to force it into the mouth and compel its being swallowed by holding the mouth and nose an expedient which is, I fear, too frequently resorted to, and of which I personally very much disapprove. In giving food or medicine by enema, however, the anatomical relations of the parts should be borne in mind and plenty of help provided, so that no danger will be encountered of doing the patient injury. I have known a fatal accident to occur from the administration of an enema. In the intro- duction of the syringe-nozzle the assistance of vision will be, in the case of an excited or frenzied patient, indispensable. 15 226 MANAGEMENT OF CASES NURSING. Medicine should be kept by the nurse under lock and key and offered to the patient in single doses, prefer- ably in liquid form. I have known a patient to make a collection of aloin, belladonna, and strychnine tablets with suicidal intent. He cleverly transferred them from mouth to waistcoat pocket after making much ado over swallowing them with the water "chaser." Tablets containing poison should be dissolved before administration. Accept no unlabeled bottle and never retain one in the medicine closet if the label is lost or the inscription upon it dimmed. I have known an experienced nurse to pour from an Abilena water bottle an ounce of strong aqua ammonia. Its odor alone arrested her administering the dose to a patient. PERSONAL ATTENTION AND NURSING. The patient should be kept tidy and neat at all times. Everything about him clothing, bedding, furniture should be changed and laundered or aired at frequent intervals. Clothing and bedding must be changed immediately if soiled, and the person of the patient at each chang- ing must be carefully bathed. Do not neglect the teeth and nails. Efforts should be made to inculcate fixed habits of tidiness by inducing the patient to sit upon the chamber or taking him to the closet at stated times if he is strong enough to be gotten up from bed. The condition of the bowels should be carefully looked after that constipation or other derangements may not ensue. Heed should be given that the patient urinates at regular intervals. Patients laboring under excite- ment fail to empty the bladder from inattention; pa- tients suffering from depression, because of apathy and indifference. Paretic patients often have distention of the bladder because of lack of power to expel its con- MANAGEMENT OF CASES NURSING. 227 tents, or because of the absence of the impulse to uri- nate, arising from sensory paralysis. It is important to call to the attention of the physician any suspicion of failure of the patient to empty the bladder, that the dismal accident of rupture may not occur. The details of catheterization, giving of enemata, attention to bed- sores, and care of the feeble pertain to ordinary sick- nursing. In nursing the insane it should be constantly borne in mind that symptoms of any disease, as, for instance, pneumonia, may be masked by the mental condition, and that complaint may not be made of pain, discom- fort, or even severe distress. TEMPERATURE TAKING. The rule should be to take temperature elsewhere than in the mouth. I have known a patient to bite off and swallow a portion of the thermometer. The thermometer should be sur- gically clean. EXERCISE. It is of the utmost importance that one suffering from' mental disease, whose strength will per- mit, should be taken out of doors for exercise every day in pleasant weather. Great caution should be ob- served to assure one's self that the patient's physical condition will admit of his going. He should not be taken for exercise to-day because of a general direc- tion to this effect yesterday, but the advisability of the act should be invariably considered before a step is taken. There should be care that the walk is not too long ; that the patient is not fatigued by it ; that he is not taken into places of danger ; that he is not exposed to the cold, or to the heat of the sun unduly ; that he is suitably clothed ; that he is not permitted to sit upon the damp ground or loiter in places where he may be 228 MANAGEMENT OF CASES NURSING. seen by others and his condition made the subject of remark. In maniacal excitement, unless the strength is too much reduced (and in a decision of this kind the opinion of the physician should be taken), walks are frequently well borne and profitable. The restlessness of mania must have vent. To repress it too much is to intensify excitement and do the patient harm. In the occupation of walking out of doors there is a diver- sion of the nervous energy into healthful channels. The sleep and the appetite are better, and all the bodily functions are more satisfactorily performed in conse- quence of it. Fresh air in abundance is introduced into the lungs ; the blood is more rapidly and perfectly oxygenated it is of a more favorable quality to nourish the brain. The bodily secretions are quick- ened. That form of exercise is the best in which the largest number of muscular groups can be utilized, and, in depression, that the most satisfactory which intro- duces a variety of healthy percepts into consciousness. This is true for obvious reasons, it having been shown under "Limitations of the Will" that a thought can- not be dismissed by mental effort, but must be sup- planted by another in order that it may be removed. Patients suffering from mental depression are fre- quently averse to going out of doors, or even into the society of their fellow-patients. In overcoming this disposition, the nurse is promoting his patient's well- being and lessening the intensity of morbid mental operations by presenting healthful subjects for con- templation. Pleasurable emotions stimulate vital activity. All are aware of the depressing effects of. trouble bad news, mental shock how they take away the appetite and derange the bodily functions. The MANAGEMENT OF CASES NURSING. 229 contrary is true of pleasurable emotions. All of the vital functions are stimulated by these to greater activ- ity ; hence their importance as aids to the recovery of the insane. In depression with hypochondriasis there is, gener- ally speaking, disinclination to take exercise, and it is important that this disposition should be met and the determination of the patient to remain indoors, in his room or in bed, be thwarted. Much caution should be observed, however, that undue exercise is not taken, and the patient's complaints and protests should be duly weighed. 1 EMPLOYMENT and DIVERSION are desirable for the same reasons that exercise is desirable. Through them healthful topics of thought are introduced to displace those of a morbid character: the muscular action is diverted from unhealthful into healthful 'channels; voluntary control is stimulated; the ability to fix the attention is increased; restlessness, disorder, and de- structiveness are diminished; sleep, appetite, and the bodily functions are improved. The furnishing of a congenial diversion, such as taking a patient to a con- cert or a church service, often supplies an effective motive for self-control and is a stepping-stone to his recovery. In recent mental diseases employment is of service 1 1 once knew a hypochondriacal patient to be sent out of doors for a walk by her physician, it being believed by him and by all who had dealings with her that her objections to going out were purely mental, and that there was no physical condition which would be a barrier to the exertion. On the morning in question she had gone but a few steps when she fell dead from heart failure. 230 MANAGEMENT OF CASES NURSING. for the immediate well-being of the patient, substitut- ing new topics of thought and directing the energy along useful lines. In arresting the tendency to dementia, employment is of the utmost value. In settled dementia we not only find employment an outlet for nervous energy, which is apt to expend itself in moving restlessly to and fro, in picking at the clothing, and in degrading habits, but we possess in it a means of re-education of the brain, of opening new routes of nervous travel, and bringing into action groups of nerve-cells not formerly in commission. As my experience increases I am more and more convinced of the practicability of employing almost all patients, no matter what their mental condition may be save those, of course, en- feebled in body from paralysis or other cause in some line of work. The employment may be simple, but will be found sufficient to contribute materially to the welfare of the patient and that of others. Knitting is an employment of great value. Knowing my interest in it, a patient once wrote the following, acrostic : Such a great panacea for all human need, At last is discovered they say; Let me tell you no joke is intended, indeed, Vive la science! (of knitting) this day. Away with such nonsense as powders and pills, They rather increase than diminish our plight, If all I have heard be quite true, then it kills Oftentimes to be dosing from morning till night Now or never this fact must be truthfully told, It is work that makes all life complete without blight No distinction, no rank, no, not barrels of gold MANAGEMENT OF CASES NURSING. 231 Will give one the joy that one neatly knit bag, Or a pair of golf stockings just done to a turn, Rosy mittens, bed slippers, a handy wash-rag, Knit, my friends, by the sweat of your brow. You shall learn Contentment. The reason is evident now. Why the Doctor's accustomed to knitting his brow. By introducing variety (not too much variety, but a little diversion and change) into the daily lives of patients, we are helping mental action, substituting new topics of thought, and widening the mental horizon. Patients should be induced to do different things or the same thing in different ways. If a morbid tendency leads one to remain in a certain posi- tion for hours at a time the current should be inter- rupted; something new presented in exchange for the old. If a particular seat is selected in obedience to a habit of dementia, change the location of the chair, or furnish another surreptitiously. If the patient insists upon sitting in his room unoccupied and absorbed in morbid thoughts, induce him to work, break up in some way the dry routine, and force, little by little, little by little (not too rapidly, lest he tire), some healthful concepts into his consciousness. The use of games should be general and frequent, and in patients who have no natural desire for amusements a taste should be cultivated. Be it ever so simple and child- like, occupation or amusement of some kind intro- duced into the patient's life will be of great service to him. In the progress of mental disease brain waste is rapid. Restoration and repair are brought about during SLEEP. It is consequently important that nothing should interfere with the patient's obtaining 232 MANAGEMENT OF CASES NURSING. a suitable amount of rest. Exercise and employment in the daytime and the establishment of fixed habits of living go far to bring this desirable state of things about. Inability to sleep frequently depends upon actual starvation of the nerve centers. Under such conditions the taking of a little food just before re- tiring as a glass of hot milk or a cup of cocoa or chocolate may be all that is necessary to induce re- pose. A warm bath or cool sponging to the spine will also be found of value in some cases. Where medicine is prescribed for the purpose of producing sleep it should be administered under the careful directions of the physician; should, as a rule, not be given where circumstances warrant its temporary withdrawal; and should be discontinued as soon as habits of sleep are measurably re-established. In this matter, as well as in others connected with the management of such cases, the patient's individuality should be carefully studied. The reason why he does not sleep should be discovered, if possible, and means taken to meet the indication. One persistently wakeful and noisy at night this from sheer timidity when sleeping alone may be quiet and calm and rest well in a dormitory with others. A patient whom I once had under obser- vation, who for years was thought to require a hyp- notic at night because of noisy demonstrations, slept like a child after being placed in a covered bed, be- cause he believed that while there his enemies could not steal his sheep. Another patient, sufferihg from a chronic form of disease, was noisy the night through until afforded one day the opportunity to lie down for an hour. That night she slept, and on succeeding nights, if she had napped in the daytime, she rested MANAGEMENT OF CASES NURSING. 233 well. Aching teeth, of which the patient may not com- plain, are an occasional cause of sleeplessness. Prolonged rest in bed is frequently necessary. Certain cases of manic-depressive insanity of the alter- nating type are, in disturbed periods, quieter and more comfortable if permitted to remain alone in bed than if up and about. Here exhaustion of the brain is less, the horizontal position affording a means for more perfect nutrition of that organ. Fewer percepts are introduced into consciousness, and mental confusion is less. In ordinary recurrent cases this plan would be inadvisable, but in those exceptional ones attended by much confusion and a high grade of excitement it is frequently of great service. In acute exhaustive con- ditions the patient should be kept in bed to prevent further physical decline, and should be nursed as one in the delirium of fever. In depressive states attended by great physical prostration, the mental operations are often surprisingly improved by a few days in bed in a horizontal posture this for the reason already given. The objections to rest in bed are: the dangers of suicide, of the formation of habits of inactivity, and of the development of untidiness. These objections may be met by watchfulness and attention. Bathing. The presence in the room, even when her assistance is not actively needed, of the nurse, is neces- sary to ward off the danger of intentional drowning, of scalding, or of accident. During the prolonged bath, pulse count should be made at frequent intervals and if any marked acceleration or lowering of the rate is discovered the fact should be at once reported to the physician in attendance. Where his advice is not 234 MANAGEMENT OF CASES NURSING. available, the bath should be immediately suspended, the patient placed in bed and cooling applications made to the head and upper part of the body. Correcting Pernicious Habits and Checking Mor- bid Impulses. As the tendency of the insane person's mind is toward neglect in personal appearance, dis- order, lack of self-control, contemplation of morbid subjects, and impulsive acting, the energies of those having the responsibility of his care should be di- rected to the establishment of neatness, the correcting of habits of neglect, the repression of evil or per- nicious tendencies, the substitution of natural for un- natural thinking, and the restoration of habits of self- control. This is symptomatic treatment. In the care of the insane punishment should never be employed. Punishment is the infliction of pain for a crime or fault. The insane person, having lost by disease his ability to feel, to think, and to act in a natural manner, is not responsible and should never be punished. It is appropriate, in my judgment, to supply certain motives to self-control ; as, for instance, withdrawal of tobacco from those untidy in its use; or denying those who have been guilty of improprieties the privilege of at- tendance upon assemblies. These disciplinary meas- ures, though possibly regarded by the patient himself as punishment, cannot justly be thus considered. They are steps taken with the end in view of promoting the patient's self-respect and establishing habits of neat- ness and self-control. The withdrawal of food or any of the necessities of life, as a correction for a fault, could never be, under any circumstances, excusable, though, on the contrary, on rare occasions the furnish- MANAGEMENT OF CASES NURSING. 235 ing of a reward as fruit, candy, or a delicacy be- cause of some particularly praiseworthy and com- mendable conduct, may be wise. Scolding or harsh and ungentlemanly or unladylike language should never be indulged in. It does no good and is the source of no end of disagreement and trouble. One is never excusable for incivility; and any tendency in this direction which the nurse is conscious of in himself or which he sees in others patients or employees should be corrected where practicable. Employ the prefix "Mr." or "Mrs." invariably in addressing your patient. Make requests ; do not com- mand. A request pleases; a command antagonizes. An attitude of imperiousness toward the patient dimin- ishes his regard for the nurse, and if the "order" is obeyed it is at the cost of his self-respect. The nurse should be equally careful not to be patronizing. To the majority of patients a patronizing air is highly offensive. In the government of patients, a firm, judicious posi- tion should be taken and maintained. Be sure of the right and propriety of the course, then consistently pursue it. Let the judgment be made up calmly. Waste no time in arguing or in reiterating again and again what will be done in case compliance with a re- quest is not forthcoming. The repeated You shall's, which only call forth the / shall nofs, anger both parties and are unseemly. After calmly and dispas- sionately telling your patient what course will be taken in case of indulgence in some particular line of con- duct, carry out the plan without further talk if the conduct is repeated. "How do you get on with this patient so well nowa- 236 MANAGEMENT OF CASES NURSING. days?" I once asked a nurse. "I guess it is because I've quit having the last word," she replied. Avoid too much talking; heed reasonable requests; take a firm and judicious position and maintain it. The ideal nurse is calm, unassuming, serene, and well poised, not too talkative, but responsive. He loses no time by false motions and does not require to do work twice over because of failure to perform it well in the beginning. He does not make the mistake of being overzealous. He realizes just how far he may be suggestive without antagonizing his patient and arousing irritability and resistance. Some of the best-meant efforts fail from overdoing. This is notably true of those which are attended by too much talking. Talk often tires-. In conversation with one whose mental powers are weakened by disease, one should always remember the danger of over-stimulation producing mental fatigue and confusion. The ideal nurse performs his duties noiselessly, spends no time in getting ready to do, wastes no words about what he is planning, but quietly and determinedly acts upon his best judgment. There is no assumption of arrogance in his demeanor, no blow and bluster, no fuss and feathers. He merely displays a quiet as- sertiveness and a fixed resolve, the effect of which latter is intensified by the unostentatious, unobtrusive manner behind it. It is the tactful, the discreet, the judicious man, not necessarily the one of great physi- cal strength, who best succeeds in the management of cases of mental disease. Great physical strength is desirable only if there is present with it that gentleness in its exercise which one of well-disciplined mind dis- MANAGEMENT OF CASES NURSING. 237 plays. There is danger if its possessor is led into the error of relying upon it to the neglect of those means of management which are the result of thought, good judgment, and careful study. I once knew a nurse who was affectionately dubbed "Charles" by the gentleman for whose wants he was providing. "How do you get on with Charles ?" I asked the patient, one evening after having during the day, myself unob- served, witnessed the relations of the two while out walking, noticed the self-contained manner of the nurse and his judicious meeting of what might have proven a serious episode. "Very well," was the gentle- man's reply ; "very well, indeed. He has his own way usually. Charles is a very determined man, a man of very few words ; but when he says come, you might as well come." One should be determined, but invariably polite. In- sistence against the will of another upon a course of action is robbed of its offensiveness if it is politely made. One should not say "come" unnecessarily and should be very careful not to take a position with a patient which he cannot defend. He should never threaten something which he could not do with proper regard for the welfare of the patient and the institu- tion whose reputation he has in his keeping. When necessary to say "come," say it kindly. "I would if I were you," is an expression infinitely less repellant than "you must"; but even these unpleasant words may be deprived of offensiveness by a gentle apologetic manner in the speaker. Never say "you must" unless compelled to. If what you ask is not heeded, do not repeat the request, but gently and firmly enforce compliance with it. 238 MANAGEMENT OF CASES NURSING. MANUAL RESTRAINT, when necessary, should be ap- plied with the least possible show of force, and never with violence. Forcible control may be necessary to protect the patient from himself and to protect others from him. It is also expedient to prevent bad habits and improprieties, to correct tendencies to restlessness and excitement, and to promote self-control. In my experience, force judiciously applied and used as a last resort is rarely, if ever, complained of, and does not give rise in the mind of the patient to a permanent grudge or grievance. If, however, the exhibition of force is the last link in a chain of unpleasant circum- stances, for which the nurse is to blame, its employ- ment is not apt to be forgiven. To illustrate : A com- mand to do some particular act is made, and is opposed because of the gruff or authoritative manner behind it; a dispute arises; attempts to coerce are made and resisted; both nurse and patient become angry, and in the end the patient suffers forcible con- trol for that which was not his but the other's fault. He is irritated and affronted, and justly so. He has been treated badly. The surrounding's and person of the patient should be spotlessly clean. Efforts should be made, by intro- duction of pictures, books, pretty furnishings, musical instruments, and games, to substitute healthful for mor- bid topics of thought. Seek to get the patient employed. One is always more self-respecting when useful. In the correction of certain vicious habits, more or less frequent among those whose self-control is weak, active manual employment in the daytime and watchful attention at night are the only agencies upon which safe dependence can be placed. MANAGEMENT OF CASES NURSING. 239 The suspiciousness of patients is best met by frank- ness and consistency, or, as mentioned under "Adminis- tration of Food," by apparent indifference. It is important that the nurse should be in the con- fidence of the patient; hence the necessity that the latter's early impressions of his surroundings should be favorable. In order to counteract morbid impulses, the nurse must know about his patient's mental opera- tions. Unless in his confidence, these may not be revealed. Patients are suspicious of what they do not see. It is unquestionably true that numberless accusations of abuse are based upon sounds which patients hear issuing from rooms with closed doors. Hence, so far as is consistent 1 with modesty and propriety, permit patients to see how others are cared for. In the matter of delusions, be frank, but do not an- tagonise. If a patient states that he is God, it is en- tirely unnecessary to retort: "No; you are not." If, however, he asks : "Am I God ?" it is the duty of the nurse to say : "We are taught that the Lord has never appeared upon earth but once, and then in the person of Christ, many years ago." In this or in some other way the question may be evaded, or the nurse may quietly and pleasantly say : "No, sir ; that is an errone- ous belief." Further discussion of the matter is un- necessary and inadvisable. This applies to recent cases, on the one hand, and, on the other, to cases having confirmed delusions of long standing. In the case of a convalescent patient, however, just as the mental cloud is lifting, timely, judicious conversation may contribute much toward assisting him to correct 1 See "Homicidal Impulses," page 241. 240 MANAGEMENT OF CASES NURSING. morbid judgments and control diseased impulses. "He (pointing to the nurse) is the first man that ever told me those ideas of mine were not right," said a patient. "At home, when I said 'I have the light here' (opening his coat), they told me it shone all over the room. He told me that wasn't so, and that such ideas would not be believed here." Homicidal assaults may arise in consequence of delusions, or impulsive acts not intentionally homicidal may result in death. The delusions which lead to homicide are: first, those oi persecution or of con- spiracy ; second, those of impending want and misfor- tune. The only effective precaution against homicide is vigilance. It is the duty of the nurse, in cases of quarrels between patients, to interfere. This may often be cleverly done by requesting of one his assist- ance in some form of work at another part of the room. Knives, scissors, and sharp instruments should always be kept under lock and key. Brooms, mops, dusters, and articles of this kind which may be used as weapons, should never be left about, but locked up immediately after using. Chamber utensils should be dealt out only under watchful supervision. Bath-tub keys, which may be used like a brass knuckle, or with which hot water may be drawn, should never be per- mitted to come into a patient's possession. The search- ing of clothing, bedding, and rooms should be sys- tematically done in many cases daily, in the majority of cases twice a week. A threatening blow may some- times be arrested by seizing the roll of the coat with both hands, and quickly drawing the coat down upon the arms. MANAGEMENT OF CASES NURSING. 241 Homicidal imposes may exist for years under con- trol and then suddenly develop ; hence the importance of being fully informed -of the character of the pa- tient's mental -operations, and being ever on the alert for the "unexpected," which is said always to happen. The impulsion to homicide may arise in strange ways. A patient in an Eastern asylum who required to be repeatedly fed artificially and always strenuously objected to the process, was struck and instantly killed by a morose and reticent patient who had watched the feeding process and had not approved of it. In ac- counting for his conduct the homicidal patient said, "I killed him so that he would not have to be fed any more." Suicide and self-mutilation may be prevented by close watching and attention to the care of knives, sharp instruments, broken glassware and crockery, and other articles with which injury may be inflicted. Suicide by precipitation is relatively frequent; hence, the necessity for watchfulness when patients are out walking, that they do not go into dangerous localities ; that they have no opportunity to throw themselves be- fore automobiles or street cars, from high places (as ladders or fire-escapes), under loaded wagons, or into water. Care should also be exercised that they pick up nothing with which they may injure themselves subsequently. Indoors, attention should be given to suicidal patients when going up and down stairs, and the door to any shaft should be kept closed and locked every moment when the nurse is not standing before it. Be watchful lest suicidal patients throw them- selves into open fireplaces, scald themselves, drown themselves in bath-tubs, hang themselves in roller 16 242 MANAGEMENT OF CASES NURSING. towels, in sheets tied at the window-guards, or in skeins of yarn suspended from gas-fixtures. A pa- tient whom I once knew jumped up from the rocking- chair in which she had been quietly sitting, faced the chair, and sprang into it, only to throw 'herself back- ward upon her head. She died almost at once. Un- avoidable accidents of this nature will sometimes arise, notwithstanding the most careful watching ; but let no patient be afforded the means of committing suicide, homicide, or self-mutilation through the carelessness of the nurse. Do not make the mistake of believing that because a patient continually talks of suicide he will not carry threats into execution. Several fatali- ties have occurred in my knowledge among patients of this class. Irritability. This is frequently an expression of physical pain of which the patient does not complain. Its source should be looked for in sleeplessness, head- ache, aching teeth, abdominal pain, constipation, dis- tended bladder, etc. MECHANICAL RESTRAINT. In the early days of my hospital experience it was thought necessary to use me- chanical restraint often. Employment, night-nursing, the prolonged bath, and personal attention have done away with this necessity, until now in a well-ordered institution resort to it is a conspicuous rarity. It may be necessary in exceptional cases, but should never, except in a grave emergency, be applied without the previously expressed sanction of a physician. A pa- tient in restraint should be visited at least once each hour; the bedding should be inspected, and necessary changes made. A patient in restraint is helpless and necessarily more or less uncomfortable from the limi- MANAGEMENT OF CASES NURSING. 243 tation of muscular movement. Much can often be done to mitigate discomfort by friction of accessible portions of the body, by cold sponging to the face and neck, or by the application of water warm or cold to the forehead. Bear in mind to offer drinking water at frequent intervals to one in this uncomfortable situation. SECLUSION. The isolation of a patient may be ex- pedient for his own benefit, or for the good of others. When done, this should be with as little demonstration and display of force as possible, and only after due warning has been given. The course may be neces- sary; first, because of noisy and disorderly conduct; second, in hysterical patients as a measure of good (lack of self-restraint in these cases always being greater when the patient is among other people) ; third, because of obscenity or indecency; fourth, to with- draw the nervous subject from perturbing influences and thus diminish mental confusion. 1 Patients in seclusion should be visited frequently. After quietly unlocking the door (doors should always be locked and unlocked quietly) the key should be withdrawn and placed in the pocket before the door is opened. Both hands of the nurse are then free. The practice of unlocking a door and pushing it forward, hand on key, is extremely reprehensible and danger- 1 Epileptic patients during confusional states are frequently benefited by confinement to bed. Noise and disorder are lessened, and, fewer percepts coming into consciousness, re- action, as manifested in impulsive assaults, is diminished. After secluding the patient, the door should be locked quietly and without ostentation, or may be left unlocked if it is believed that the patient will respect the injunction to remain within the room. 244 MANAGEMENT OF CASES NURSING. ous. In entering the room of one who has broken some piece of furniture and is making threatening demonstration with a weapon thus secured, an effec- tive protection is a mattress held before the foremost person. By means of this the patient may ' be crowded back and disarmed. The objections to seclusion are : the danger of sui- cide; the danger of increasing irritability; the danger of untidiness. A suicidal patient should never be secluded except with the previously expressed consent of the physician, and, if apart from others, should be carefully, looked after. Seclusion sometimes increases irritability, ill feeling, and waywardness. When this occurs harm results and the measure is inexpedient. The disposition to burn and the tendency to steal are observed in different forms of insanity. The fact that these symptoms are conspicuously manifested in some cases has led to their being improperly dignified by special names for disease: as pyromania and klepto- mania. The tendency to burn is most frequently ob- served in connection with chronic delusional insane conditions and in imbecility; the tendency to steal in the early stages of paretic dementia, property being appropriated by the patient under the delusion that it is his own. Patients who are demented are apt to secrete articles of no value, or little value, and unless carefully observed get together accumulations of rub- bish and useless trumpery. Searching the clothing, the bedding, and possessions of patients for matches and other articles collected, and extreme watchfulness to prevent things of this nature falling into the patient's hands, are safeguards against accidents from these sources. MANAGEMENT OF CASES NURSING. 245 DESTRUCTIVENESS. Certain patients are as suscepti- ble as little children to rewards, and right doing may be stimulated by promises of such. Where the habit of destructiveness, particularly destructiveness to clothing, is thoroughly formed, however, it is difficult to correct it and the ability of the patient to restrain the impulse to tear soon wears out. One patient whom I knew was offered by the superintendent a penny a day for every day that he kept a new suit of clothes in good order. He received his penny each day from Monday until Saturday inclusive. On Sunday night he was found in a state of great dilapidation. "Oh, Frank, I am very sorry to see you in such a plight," said the superintendent. "You have not earned your penny to-day." "Well," was the stuttering reply, "I'll be d d d if I'll work S-S-S-undays." ESCAPES. In these days of open-door halls, employ- ment out of doors, and the giving of larger and larger liberties to patients, escapes will unfortunately occur. They should never be chargeable to lack of vigilance or to disobedience of rules or regulations. Escapes, as other accidents, only too frequently take place as the result of neglect of printed rules. Remember that the escape of a patient may mean a homicide, an act of arson, a suicide, or some ghastly episode, account- ability for which would be deeply regretted. Never, under any circumstances, talk of the condi- tion of any patient to any person not entitled to re- ceive information about him. It is as true of the nurse as of the physician that highest efficiency is not reached without the develop- ment of the spiritual side of the nursing art. It is even more true in fact as the nurse's contact with the pa- 246 MANAGEMENT OF CASES NURSING. tient is infinitely closer and opportunity for helpful suggestion is correspondingly more frequent. It is important that the nurse should be early imbued with the idea that medicine-giving is not the alpha and omega of treatment, even when it is a question of the relief of pain, which may be so readily quieted by re- sort to what a patient once stigmatized as the "hypo- devil." It is feared that many nurses with carte blanche to administer them too early turn to sedatives and hypnotics and give them in too liberal quantities. Strong suggestion suffices in many cases. It was once remarked by a surgeon in my hearing that a certain nurse trained in a sanitarium making little use of drugs was the most efficient he had found in the care of surgical cases. She was resourceful, had ways of meeting the little plaints of patients resting them by change of position, rubbing them or readjusting bed- clothing that were frequently disregarded by the surgical nurse of general hospital training. It is, perhaps, not too strong a statement that the emotions have a weighty influence in the repair of tissues. It is a fact of the commonest experience that emotional depression is a constant accompaniment of operations upon those organs most liberally supplied by the sympathetic nervous system. That healing of such parts after surgery may go on satisfactorily, it is the custom to divert the patient so far as possible from contemplation of the local symptoms by taking him from bed and supplying entertainment. That this may be overdone goes without saying, but the adoption of the method by surgeons indicates how important to the healing processes a cheerful play of the emotions is regarded. MANAGEMENT OF CASES NURSING. 247 From among nurses caring for the insane whom I have known there might be constituted a large army of men and women, than whom none could be more loyal, true, devoted, and self-sacrificing. If their merits have sometimes seemed to fail of appreciation they are at least entitled to the comfort that springs from the reflection : "Charity ever finds in the act reward." PART VI. THE PREVENTION OF INSANITY. "My father thinks that when he has paid for my care in Oak Grove he has done his full duty and all that was possible for me ; whereas, if he had begun my training years ago' at home and started me in a way to help myself, my trouble might have been escaped." 1 This observation of a patient recovering from a manic-depressive attack is full of food for thought and furnishes a possible keynote to the prevention of a considerable number of cases of insanity. Through mental and physical hygiene, but in no other way, may the handicapping influence of heredity perhaps be overcome. The last generation has largely lacked disciplinary training, education in self-control, stimu- lation to usefulness and the development of individual resourcefulness. Everything has been undertaken to smooth the path and disclose the "easiest way" for the children of the well-to-do. (I mean the rich. "Well-to-do" might imply well doing which is un- fortunately far from the fact). On the other hand 1 Dr. C. Macfie Campbell writing in the Journal of Mental Hygiene for April, 1919, says : "The lack of guidance in childhood, adolescence and early adult life is one of the causes of the development in the adult of a great variety of nervous and mental disorders varying from frequent head- aches, peculiar mannerisms, anomalies of mood, odd interests and enthusiasms to disorders of conduct sufficiently pro- nounced to be called insanity." (248) THE PREVENTION OF INSANITY. 249 children of the poor and those in moderate circum- stances have too often been raised in the sordid atmosphere of cities and in contact with vice, filth, and the daily grind. In earlier times school children were drilled in the fundamentals : through repetition they memorized and whatever was acquired was stored up and utilizable. Nowadays anything bearing the remotest resemblance to memorizing must be avoided lest fatigue ensue. Even the multiplication-table has been disparaged. In the years following the civil war, children were imbued with patriotism and developed love of coun- try through the songs they sang, the conversation of their elders, the addresses they heard on the Fourth of July. The scream of trie eagle is by no means so discordant a note as our internationalists and pacifists would have us believe. Education was in the line of preparedness 2 for the vicissitudes of business and social life as well as for resistance to aggression. To use the expression of the great American cow- boy, they became self-helpful and self-defensive through "rustling" for themselves. Military organi- zations were popular among the boys and the drill at home and yearly camp kept alive a spirit of loyalty, service, and obedience. There were no "malefactors of great wealth" in the middle west, principally no doubt because "great wealth" was not in evidence. Fifty thousand dollars was regarded a colossal fortune. 2 After the visit a few years ago of a pacifist whose voice recalls the "sounding brass" of the Scriptures, an Oregon schoolmaam objected to her pupils marching in and out two by two because it "savored of militarism." 250 THE PREVENTION OF INSANITY. There was individuality in work and enterprise. Every little town and hamlet had its blacksmith shop, drug store, drygoods store, grocery, cooper shop, cob- bler and shoe shop, to say nothing of its brewery where a wholesome beverage was obtainable and to which mother sent for yeast for baking. Children raised in villages .and small cities had in common with farmers' children the advantage of a small garden to cultivate and acquaintance with the care of cow and horse and pig. Families largely made their own but- ter, salted pork, corned their beef, made soap from the product of the ash barrel and refuse fats, stored vegetables and fruits for the winter. There were relatively few books but there was a wonderful literature. The National Fifth Reader was a veritable storehouse of the gems of English, and daily reading aloud in school cultivated the memory and developed in the pupil a taste for the good and a certain facility in intonation and expression. It also taught him orthography. Exercises opening the day's school activities comprised reading from the Bible, singing, reciting the Lord's Prayer, or reading from the Prayer Book. Competition in classes and "spell- ing down" contests established the principle of merit. There was no favoritism except for the deserving and standards based upon social position did not exist. Around the stove in the center of the school-room, pupils ate their luncheon at noon and made one an- other's close acquaintance. In the sports at recess there was general participation. Playing baseball with the lungs and vocal cords from bleachers was not the vogue in those days of blessed memory, and com- mercialized athletics were practically unknown. THE PREVENTION OF INSANITY. 251 Boys were taught to provide their own amusements. There were no movie shows to deceive one into the belief that he had read Les Miserables or Oliver Twist, in watching the film. Beadle's Dime Novels, the nearest approach to the sensational which came in the boy's way, were wholesome and completely clean. I know for I have read scores of them. Girls were taught housekeeping and for an accomplishment, to play the piano or guitar. There was no Victrola to furnish a purely sensuous satisfaction without effort. The boy cared for a horse, rode him bareback, drove him in the summer to take his best girl to the picnic and in the winter in the swell-body cutter to the candy pull or country dance. There were no auto- mobile cushions on which to loll at ease and dream while flying along macadamized city streets or through the whirling dust across country. There was almost invariably individual output in entertainment and corresponding appreciation of that which had cost something in effort. The boy and girl were taught, respectively, to work in the garden and kitchen. They were disciplined to obedience of and respect for their seniors. At table pernickety choice and pet aversions as to food were not permitted. Children were supposed to act upon the principle "whatsoever is set before you, eat, asking no question for conscience sake." 1 1 Regarding children's caprices as to diet, Dr. Lewellys F. Barker wisely writes (Journal of Mental Hygiene, April, 1919). "Parents should set the example of eating all kinds of food regardless of choice and no child's likes and dis- likes in regard to diet except in rare instances of undoubted idiosyncrasy should be very much heeded." 252 THE PREVENTION OF INSANITY. There was no coddling of governesses, no relegation of mother's prerogatives to others, no indulgence on the part of private tutors. The French poodle and monkey dinner were unknown. Children were not shielded from contact with the winds of Heaven that might mayhap visit their cheeks roughly. They were not transported in ener- vating ease to and fro between town house and sea- side resort or encouraged in the idleness and self- indulgence so dear to the heart (or stomach) of the nouveaux riches. And what of all this? I realize in making the com- parisons that the possibilities of development for chil- dren along the former primitive lines are greatly im- paired by the increase in urban population and its incident industrialism and crowding, but I verily be- lieve that much of the insanity in the young appearing in recent years could have been prevented had home and school conditions approximated those of the seventies. What can be substituted for the old fashioned to meet modern requirements and minimize deteriorat- ing influences? I answer among other things, en- couragement of the Boy Scout movement, and univer- sal military training. The desirability of the latter is set forth in the following resolutions of the American Medico-Psychological Association adopted in 1916. "WHEREAS, In the prevention of mental and nerv- ous disease the development in early life of a high de- gree of mental and physical resistance is most impor- tant, and THE PREVENTION OF INSANITY. 253 "WHEREAS, Military training promotes in the in- dividual strength of muscular and bony tissues, im- proves organic functions, quickens perception, fur- nishes discipline in self-control, inculcates obedience and creates respect for authority: therefore be it "Resolved, That the American Medico- Psycho- logical Association strongly recommends universal military training and urges legislation to this end." At the pubescent age the boy is a bundle of con- flicting and bizarre emotions. He requires a steadying influence and preponderance of the commonplace. Military training offers this. For the girl at the same period, occupation in household activities, washtub and all, supervised by experienced teachers of domes- tic science, furnishes the best alternative to that which the old-fashioned home could offer in the field of employment. For both boy and girl from twelve to eighteen, transfer of residence for three months every year from Sillyville to the country, and active participation in farm work would be profitable. Mental Hygiene Associations and philanthropic organizations could scarcely find better use for their money and energies than in promoting such an enterprise. Tendency to day dreaming, self -scrutiny and ex- travagant imagining, quite frequent in children leading idle and self-indulgent lives should be overcome by diverting their activities into healthful, matter-of-fact channels. Dr. Levvellys F. Barker writes: 1 "During adolescence the child should be encouraged to face the real situations of life, when confronted 1 "How to avoid spoiling the child," Journal of Mental Hygiene, April, 1919. 254> THE PREVENTION OF INSANITY. with them, and should be kept from turning away from them or denying their existence or feeling suffi- cient satisfaction in the wish fulfillments of day dreaming and phantasms. The so-called "autistic thinking" which avoids reality and which indulges in pleasurable emotional states at the expense of whole- some objective activity is to be recognized when it exists and any excess of it is to be combated, not directly by the prohibition of the pleasure seeking automatism but rather indirectly by sympathetic guidance in the* process of "reality thinking" and by the encouragement of objective activities that compel plungings in the cold waters of actuality, that force swimming to avoid sinking, thus educating to self- reliance." Sex education for boys and girls is of prime im- portance. To the girl especially, who grows up in ignorance of sex relations, the demands which motherhood involves, and the perils which menace from impure sex contact, there should be perfectly plain speaking. I myself believe that the differences in sex conformation should be early visualized through prints, photographs, or statuary that curiosity may not lead to conjecture and that in turn to errant emotionality. The latter in hysterical organizations may entail disastrous consequences. (See chapter on Hysteria.) On the other hand it is desirable to speak of the over-development of the intellect in certain girls who attempt simultaneously to suppress or repress certain elemental emotions and yearnings. The reproductive urge is a biologic fact and the effort to stifle it through attention to so-called "higher" cultural ob- THE PREVENTION OF INSANITY. 255 jects is in the last analysis mainly camouflage, self- clieating, and pretense. To control is the problem to deny the fact is futile. I quote from the narrative of one mature in intellect though young in years who while pursuing an advanced course of study broke down and underwent a manic-depressive attack. "Marriage claimed the attention of the entire group of girls and a middle ground appeared which might include marriage and literary pursuits." She com- pared the .intellectual girls with the social butterflies, typified by an acquaintance. The former lacked something that she could not make out but it was her conviction that all, especially the older ones, wanted home and children. "Did they desire," I asked, "homes ready made and expect to escape the details of housekeeping, homemaking, child-bearing, and the like?" "Not at all," was the reply. "I should say that they all, especially the older ones, were crazy to be married." Dr.- Reuben Peterson of the University of Michigan, has pointed out in an extremely practical paper on "The Relationship Between Gynecologic and Neuro- logic Conditions" that "In this group (women with neurological symptoms whose genital organs are anatomically normal but whose functions are ab- normal) may be placed the great majority of young unmarried women suffering from some form of func- tional nervous trouble with manifestations in the pel- vis, although the pelvic organs are apparently normal. Such patients not infrequently have poor family his- tories, coming from stock with unstable nervous sys- tems, where there are many instances of alcoholism, epilepsy, hysteria and mental peculiarities. However, 256 THE PREVENTION OF INSANITY. in the majority of instances the neuroses are not con- genital but acquired as shown from the fact that up to a certain age the patients have been perfectly healthy. Young women belonging to this group will be found largely among those who have developed their brains at the expense of their bodies, school girls, school teachers and people of that class. No matter what arguments may be presented for the emancipation of women, their right to choose careers which will not compel them to undergo the hazards of child-bearing, I do not think it can be gainsaid that they pay a certain price for such privileges. It is almost impossible to get at the inner life of the in- dividual, hence impossible to judge how much the un- satisfied longing for maternity may affect the nervous system. The individual herself usually fails to realize the cause of her restlessness which she seeks to assuage by more and more intellectual labor or in some cases by the diversions of society. All these causes of nervous instability are hard to grasp, diffi- cult to define, but that they exist is beyond question." The desirability of marriage for one who has undergone one or more attacks of insanity and if al- ready married, the expediency of bringing children into the world are questions which are occasionally propounded to the physician. Decision upon these matters is difficult, but over the problems the consul- tee need not concern himself unduly inasmuch as his advice will rarely be followed unless it happens to coincide with the sentiments of the seeker thereof. However, certain paths are plain. One suffering from an organic brain disease should under no circum- stances beget offspring. This is true also of epileptics THE PREVENTION OF INSANITY. 257 and confirmed alcoholics. While there is much talk of cured syphilis, my own feeling is that its existence at any time in the life of the individual should constitute a bar to procreation. A confirmed hysteric can never become a wise mother and I am shocked when matri- mony is, as is often the case, proposed for one suf- fering from this particular psycho-neurosis. As to manic-depressive cases, each must be a law unto itself. I know of no general principle to apply except to discourage marriage in one who has under- gone more than one attack. If but one has occurred and there are signs of complete recovery, if heredity is not manifestly bad and if the proposed matrimonial partner is and has been in excellent health, the venture may not prove disastrous. 17 INDEX Ability, inherited, acquired, 37 Aboulia, 166 Accretion, growth by, 1 Acting, 13 Activity, pressure of, 54, 55 Acts, automatic, 37 impulsive, 83 reflex, 36, 39 self-defensive, 37 voluntary, 36 Acute confusional insanity, 83 Administration of food, 214, 221, 234 of medicine, 225, 246 Adolescence, 73, 74 Agraphia, 28 Aims in treatment, 220 Alcohol and alcoholism, 44, 69, 86, 89, 90, 93, 94, 95, 98, 99, 257 Alcoholic delirium, 90 delusional insanity, 94 epilepsy, 99 intoxicat'on, 69, 89 paranoia, 98 pseudo-paresis, 95 Alcohol rub, 84 Alcoholism, chronic, 94 Alternating type, manic-de- pressive, 76, 150 Amoeba, 2 Amusements, 208 Anesthesia, 86 Animal kingdom, 23 Anxiety neuroses, 172 Aphasia, 28 Apoplectiform seizures, 96, 127 Apoplexy, 62 Appetite deranged, 86 Applications, hot and cold, 84, 91, 202 Apraxia, 28 Arachnoid, 4 Argyll-Robertson pupil, 87, 130 Arson, 24 Art among insane, 66 Arteries in old age, 17 Articulates, 23 Articulate speech center, 27 Assaults, homicidal, 240 Assimilation, 1 Association of concepts, 20 paths, 12 Ataxia, 28 Atrophy, 86 Attention, 53 personal, 226 Attitude toward patients, 235 Auditory center, 29 Autistic thinking, 254 Autotoxis, 214 (259) 260 INDEX. Axis cylinder, 10, 11 Axone, 10 Bath, prolonged, 84, 206, 211 Bathing, 233 Bed-sores, 127 Bed treatment, 206, 233, 243 Biology, 1 Bladder rupture, 123, 128, 160, 211, 227 Blindness, mental, 27 Blood-pressure, 159 Bones, fragility of, 128 Boy scouts, 252 Brain, 5, 7, 8, 9 Brain and mind, 5, 7, 8 Brain, association paths, 12 cells, 5, 10 concussion, 7 convolutions, 6 cortex, 10 damage to, 10 development of, 10 disease, organic, 17, 87, 123, 137, 138 disturbance of function of, 7 divisions of, 3, 4, 9 fissures, 9 hemispheres, 12 in idiots, 7 in lower animals, 8 (illustration), 5 lobes, 9 localization, 26 membranes, 4 motor area, 27 nutrition, 7, 70 Brain, pressure on, 27 tumor, 138, 164 Calisthenics, 217 Care of nails, 222 teeth, 222 sanitarium, 87, 91, 102, 175, 207, 218 Catheterization, 211 Causes of insanity, 70 constitutional, 72 direct physical, 70 emotional, 71 evolutional, 72 indirect physical, 71 involutional, 73 Cell nucleolus, 10 nucleus, 10 Cells, brain, 5 nerve, 10 Center, hearing, 27, 29 smell, 27 vision, 27 Central nervous system, 3 Cerebellum, 4 Cerebral cortex, 10 localization, 26 Cerebrum, 4, 8 Change of life, 73, 156, 159 Chemical restraint, 205 Classification of animal kingdom, 23 of insanity, 75, 76 Cleanliness, 222 Climacteric period, 74, 156, 159 Cocaine habit, 105 Cold applications, 92 pack, 211 INDEX. 261 Cold shower, 123 Collapse delirium, 81 Concept, 20, 21, 25, 35, 41, 43 Complex, 68, 122, 164 in dementia praecox, 122 in hysteria, 164 Concussion of brain, 7 Confidences of patients, 245 Confusion, 79, 83 Confusional insanity, 83 Consciousness, 4, 9, 16, 24 Constipation, 80, 84, 88, 89, 91, 102, 123, 143, 145, 149, 154, 158, 197, 198, 200, 210 Constitutional causes, 72 Contractures, 86, 138 Convalescence, 217 Convolutions, 6 Cool sponging, 84, 91, 243 Convulsions, 95, 99, 127, 138, 139, 161 Co-ordination, 27 Corpus callosum, 12 Correcting pernicious hab- its, 234 Cortex of brain, 6, 10 Courtesy, 237 Cranks, 179 Cretinism, 106 Crisis, gastric, 131 Custodial care, 217 Dangerous impulses, 79, 83 Day dreaming, 253 Defect of development, 7 Definition of insanity, 69 Delirium, 44, 77, 78, 81, 82, 90 alcoholic, 90 and fracture, 90 collapse, 81 narcotic, 89 of fever, 77, 78 of infection, 78 of pneumonia, 78 of typhoid, 78 tremens, 90 Delusion, 19, 46, 83, 94, 222, 239 visceral, 157 Delusional insanity, alco- holic, 94 Dementia, 8, 75, 231 Dementia, employment in, 230 habits of, 231 organic, 138 paralytic, 17, 87, 123 paretic, 17, 87, 123 praecox, 44, 57, 80, 108 complex in, 122 hebephrenic, 110 katatonic, 116 paranoid, 117 symbolism in, 64, 67 with paralysis, 138 Dendrite, 11 Depression, 75, 85 management of, 208 Desire and will, 35 Destructiveness, 245 Development of mind, 13 Diagram of sympathetic, 31 Dipsomania, 93 Direct physical causes, 70 262 INDEX. Discipline, 235, 248 Distention of bladder, 123, 128, 160, 211, 227 Disturbance of emotion, 52 higher reflexes, 53 ideation, 52 intellection, 7 judgment, 51 memory, 52 perception, 44 reasoning, 51 sensation, 43, 44 volition, 53 Diversion, 229 Division of animal king- dom, 23 brain and nervous system, 3, 9 Drug addiction, 99, 105 Drugs, depressing, 202, 206, 209, 246 Dual personality, 169 Dura mater, 4 Education of animals, 4 blind, 25 child, 36, 37 deaf, 25 emotions, 34 volition (will), 39 youth, 251 Ego, 18 Egotism, 51, 118 Elation, /5 Electric breeze, 88 Elimination, defective, 19, 80, 84, 88, 89, 91, 102, 123, 143, 145, 149, 154, 158, 197, 198, 200, 210 Emotion, 3, 13, 29, 30, 31, 32, 35, 41, 43, 52, 70, 246 and muscular expression, 32, 34 and organic functions, 30, 246 Emotions, disturbance of, 30, 32, 70, 71, 246 Emotional causes, 70, 71 Employment of patients, 229 of youth, 253 Encephalon, 4 Enemata, 81, 88, 91, 104, 123, 143, 149, 154, 225 Epilepsy and epileptiform conditions, 44, 69, 92, 99, 127, 160 Epileptic insanity, 160 Epileptiform seizures, 92, 127, 138, 139, 161, 209 Eroticism, 111, 126, 164, 169, 238, 254 Erraticism, 109 Erysipelas, 79 Escapes, 245 Etiology, 70 Evasion, 51 Evidence, objective, 8 subjective, 8 Evolution, 17, 73 Evolutional causes, 70, 72 Excitement, management of, 194 Exercise, 149, 154, 227 danger in, 229 Exhaustion, chronic nerv- ous, 85 INDEX. 263 Exhaustion psychoses, 81 Experiments on animals, 8 Faculties of mind, 13 Febrile delirium, 77, 80 Feeding, 214, 221, 222, 223 by tube, 214, 224 mechanical, 214, 224 rectal, 81, 91, 104 Feeling (emotion), 3, 13, 29, 30, 31, 32, 35, 41, 43, 52, 70, 246 Fever, 77, 80 Firmness, 236 Fissures of brain, 9 Flight, 171 of ideas, 53 Folie circulaire, 76, 150 Food, administration of, 81, 91, 104, 214, 221, 224 refusal of, 81, 91, 104, 214, 224 Forms of insanity, 74 Fractures, 128, 160 Fragility of bones, 128 Freud, 57, 114, 155 views of hysteria, 155 Fugues, 171 Ganglion, 3 Gastric crises, 131 General considerations, 43 management, medical, 193 nursing, 220 paralysis, juvenile, 137 of the insane, 123 paresis, 123 Gray matter, 4, 5, 6 Habit, alcohol, 89 associations, 37, 38 cocaine, 105 drug, 99, 105 morphine, 99 opium, 99 Habits, formation of, 38 of dementia, 231 of destructiveness, 245 of inactivity, 231 vicious, 70, 72, 234, 238 Hallucinations, 44, 45, 46, 83, 115 in deaf and blind, 45 in dementia prsecox, 115 Handwriting, 129 "Harmless" insane, 178 Hearing, 13, 27, 29 center, 27, 29 Heart tonics, 209 Hcbephrenic dementia pra> cox, 110 Hebetude, /8 Hematoma auris, 128, 215 Hemispheres of brain, 12 Higher reflexes, 39 disturbance of, 53 reflex acts, 39 volition, 38 Homesickness, 219 Homicidal assaults and im- pulses, 135, 179, 239, 240, 241 Hospital care, 81, 87, 91. 102, 136, 175, 182, 218 Hydrotherapy, 88, 98, 144, 149, 159, 175, 206, 209, 211, 233 Hygiene, mental, 76 264 INDEX. Hyperthyroidism, 107 Hypnotics, 93, 136, 161, 202, 203, 204, 205 Hypnotic influence, 19 Hypochondria, 85, 229 Hypodermics, 84, 92, 103, 205, 246 Hypothyroidism, 107 Hysteria, 161 symbolism in, 64 Hysterical insanity, 161 dual personality in, 169 obsessions in, 64 Hystero-maniacal states, 80, 166 Ice cap, 92, 106, 143 Ideal nurse, 220, 245 Ideas and ideation, 13, 14, 20, 25, 35, 41, 43, 52, 53 impaired, 52 Idiocy and imbecility, 7, 8, 10, 106, 175 Illusions, 19, 44 Illustration of brain, 5, 9, 26 central lobes, 9 concept, 21 neurone, 11 stereotypy, 55 sympathetic, 31 touch, 15 vision, 16 volition (will), 38 Imbecility, 7, 8, 10, 106, 175 Impressions from without, 18 registration of, 20 Impulses, dangerous, 79, 83, 135, 179, 239, 240, 241 morbid, 234 Inattentiveness, 53 Incivility, 235 Incoherence, 53 Incontinence of urine, 78 Indirect physical causes, 70, 71 Inequality of pupils, 87, 127 Infection delirium, 78 psychoses, 77 Influenza, 78 Inherited attributes, 36 Inhibition and inhibitory control, 10, 39, 40 Insane ear, 128, 215 Insane, writings of, 55, 66, 111, 112, 113, 114, 120, 121, 129, 151, 152, 166, 182 Insanity, 69, 70, 74 causes of, 70 classification of, 76 definition of, 69 forms of, 74 acute confusional, 83 alcoholic delusional, 94 dementia praecox, 108 dementia with paralysis, 138 epileptic, 160 exhaustion psychoses, 81 from syphilis, 139 from thyroid disturb- ance, 106 idiocy and imbecility, 106, 175 INDEX. 265 Insanity, forms of, infection psychoses, 77 intoxication psychoses, 89 manic-depressive, 139 paralytic or paretic de- mentia, 123 paranoia, 176 paresis, juvenile, 137 pellagrous, 190 presenile and senile (in- volutional), 156 psychoneuroses and neu- roses, 161 medical management of, 193 nursing management of, 220 prevention of, 248 Insight, 57 Insomnia, 78, 81, 83, 86, 88, 90, 93, 103, 106, 142, 146, 149, 199, 202, 203, 204, 205, 232 Instinct, 4 Institutional care, 81, 87, 91, 102, 136, 175, 182, 218 Intoxication, alcoholic, 69, 89 psychoses, 89 Involution, 73, 74, 156 Involutional insanity, 156 Irritability, 242 Jelly fish, 3 Judgment, 2, 7, 12, 14, 21, 22, 24, 25, 35, 41, 43, 51 in idiots and imbeciles, 7 Juvenile paresis, 137 Katatonic form, dementia praecox, 116 Kidney displacements, 213> 214 Kleptomania, 244 Knitting, 230 Korsakoff's psychosis, 80 Language, zone of, 29 Lead poisoning, 89 Life, 1 Limitation of volition (will), 40, 228 Litigiousne-s, 180 Lobes of brain, 9, 21 prefrontal, 21 Localization in brain, 26 Lower animals, experiments on, 8 judgment and reasoning in, 5 Lumbar puncture, 37, 133 Macrocephaly, 7 Mammals, 23 Management of cases, medi- cal, 193 nursing, 220 Mania, 75 Manic-depressive, 44, 52, 56, 76, 80, 139 alternating type, 150 circular type, 150 depressive type, 144 manic type, 140 Manslaughter, 39 Man's moral nature, 33 Manual restraint, 238 Marriage, 255 266 INDEX. Massage, 88, 103, 175, 210 Mechanical feeding, 214, 224 restraint, 242 Medical examination, 50, 57, 180, 194 treatment, 193 Medicine, administration of, 225, 246 Medulla oblongata, 4 Membranes of brain, 4 Memory, 13, 14, 16, 17, 19, 20, 25, 27, 52 of percepts (loss), 27 organic, 19 Meningitis, 162 Mental blindness, 27 Hygiene Committee, 76 Microcephaly, 7 Military training, 252 Mind and brain, 8 development of, 13 faculties of, 13 Mind in lower animals, 4, 5 Mollusks, 23 Moral and morale, 33 "Moral insanity," 151 Morbid impulses, 234 Morphine habit, 99 Motion, modes of, 1, 2 Motor area, 27 Afurder, 39 Muscular atrophy, 86 inco-ordination, 53, 125 expression. 32, 34 sense, 14, 45 Nails, care of, 222 Narcotics, 86 Narcotic delirium, 89 National Committee for Mental Hygiene, 76 Negativism, 54, 56, 82, 116, 117 Nephrocoloptosis, 213, 214 Nerve cells, 10 centers, 16 Nerves, sensory, 13 Nervous exhaustion, chronic, 85 force, 6 system, 3 Neurasthenia, 85 Neuritis, 80 Neurone, 10 Neuropathic organization, 72, 108 Neuroses, 161 anxiety, 172 Nucleolus, 10 Nucleus, 10, 11 Nurse, qualifications of, 220, 245 Nursing, 226 care pf the insane, 220, 226 Nutrition, 1 of brain, 7, 70 Objective evidence, 8 Obsessions, 64, 67, 165, 168, 174 Old age, 17, 73, 74 Opium habit, 99 Opposition not negativism, 56 Optic nerve, 14 Organic brain disease, 123, 137, 138, 139 INDEX. 267 Organic dementia, 17 functions, 1, 30 memory, 19, 36 Othematoma, 128, 215 Pack, cold, 211 Paralysis, dementia with, 138 of bladder, 123, 128, 160, '211, 227 Paralytic (paretic) dementia, 123 Paranoia, 176 alcoholic, 98 Paranoid form, dementia prsecox, 117 states, 44, 64, 75, 98, 117 symbolism in, 64 Paresis, general, 17, 87, 123 juvenile, 137 Paretic dementia, 17, 87, 123 and neurasthenia, 130 Pathology of insanity, 74 Pellagrous insanity, 190 Percept and perception, 14, 15, 24, 25, 27, 35, 41, 43, 44 Peripheral nervous system, 3 Pernicious habits, 70, 72, 234, 238 Personal attention, 226 Personality, 10, 18, 169 dual, 169 Petrolatum, 210 Physiology, 1 Pia mater, 4 Pinhole pupil, 127 Poisoning, lead, 89 Politeness, 235 Pons varolii, 4 Post-febrile conditions, 79 insanity, 80 Presenile insanity, 156 Pressure of activity, 54, 55 Prevention of insanity, 248 Prolonged bath, 84, 206, 211 rest in bed, 195, 206, 233 Pseudo-paresis, alcoholic, 95 Psychasthenia, 165 Psychoanalysis, 213 Psychology, 1 Psychomotor area, 29 Psychoneuroses, 161 Psychosis and psychoses, 77, 80, 81, 89 Psychotherapy, 212 Pubescence, 72, 74 Puncture, lumbar, 87, 133 Punishment, 234 Pupil, Argyll-Robertson, 87, 130 contracted, 87, 127 immobile, 125 unequal, 125 Pyromania, 244 Qualifications of nurse, 220, 244 Radiates, 23 Reason and reasoning, 4, 5, 14, 21, 22, 24, 25, 35, 41, 43, 51 Reasoning in lower animals, 4, 5 Recapitulation, 40 268 INDEX. Recollection, 20 Rectal feeding, 81, 91, 104 Reflexes and reflex acts, 16, 21, 36, 39, 53 Refusal of food, 214, 221, 222, 223, 224 Representation, 20 Reproduction, 1 Rest in bed, 195, 206, 233 sheet, 85 Restraint, chemical, 205 manual, 238 mechanical, 242 Retardation, 54, 56 Retina, 14 Retraction theory, 12 Rewards, 235 Rupture of bladder, 123, 128, 160, 211, 227 Russian bath, 98, 123, 149 Salt glow, 123, 149 solution, 81 Salvarsanized serum, 136 Sanitarium care, 81, 87, 91, 102, 136, 175, 182, 218 Scalding, 235 Searching clothing and bed- ding, 244 Seclusion, 243, 244 Sedatives, 202, 206, 209, 246 Seeing, 13 Segmentation, 2 Seizures, apoplectiform, 96, 127, 138 epileptiform, 92, 127, 138, 139, 161, 209 Self defensive acts, 37 injury, 105, 110, 146 Self-mutilation, 131, 241 Senile insanity, 156 Senility, 73, 74, 156 Sensation, 2, 14, 19, 24, 41, 43, 44 Senses, 3, 13, 25 Sensibility, 13 Sex education, 254 Sexual weakness, 85 Simple neuritis, 80 Sleep, 231 Small-pox, 79 Smelling, 13, 27 Special senses, 3, 13, 25 Speech center, 27 Spinal cord, 4 Static breeze, 88 Status epilepticus, 161 Stealing, 244 Steam bath, 98, 123, 149 Stereotypy, 53, 54, 55, 82 Subjective evidence, 8 Suggestion, 212 Suicide, 130, 146, 159, 165, 241 Surgery in insanity, 159, 173, 213 Surgical experiences in war, 26 Suspiciousness, 239 Swift-Ellis treatment', 136 Symbolism, 58 Sympathetic system, 3, 31, 87, 246 Syphilis and syphilitic in- sanity, 133, 137, 139, 257 Tasting center, 26 Teeth, care of, 222 INDEX. 269 Temperature taking, 227 Tendon reflexes in neuras- thenia, 87 Thinking, 13 autistic, 254 Thyroid and thyroidism, 106, 107 Torpor, 78 Touch, 13 Travel in neurasthenia, 87, 217 Treatment, aims in, 220 Tumor of brain, 138, 164 Typhoid, 78 Unconsciousness, 83 Urine, incontinence of, 78 Verbigeration, 53, 54 Vertebrates, 23 Vicious habits, 70, 72 Volition and volitional acts (will), 13, 35, 36, 38, 39, 40, 41, 43, 53, 228 Volition, illustration of, 38 Vision, 13, 14, 27 Visual center, 27 Vomiting, 162 War surgery, 26 Wassermann reaction, 87, 98, 133 White matter, 4, 5, 6 Will, 13, 35, 36, 38, 39, 40, 41, 43, 53, 228 education of, 39 illustration of, 38 limitations of, 40, 228 Witchcraft, 47, 48 Word obsession, 64, 67 Writings of insane, 55, 66, 111, 112, 113, 114, 120, 121, 129, 151, 152, 166, 182 Zone of language, 29 THE LIBRARY UNIVERSITY OF CALIFORNIA Santa Barbara mi THIS BOOK IS DUE ON THE LAST DATE STAMPED BELOW. 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